**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of the facility policy, the facility failed to develop a comprehensive person-centered care plan which included timeframes and measurable results to meet each resident's medical, nursing, mental and psychological needs as identified in the comprehensive assessment for three residents, (R)7, R48 and R14 out of 25 total of sampled residents. The findings include: Review of the facility policy titled, Comprehensive Care Plans dated 08/30/2022 and reviewed/revised on 02/2024, revealed it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, to meet a resident's medical, physical, mental, and psychosocial needs. Continued review revealed the comprehensive care plan was to include measurable objectives and timeframe's to meet the resident's needs as identified in the resident's comprehensive assessment. Further review revealed the objectives were to be utilized to monitor the resident's progress, and alternative interventions were to be documented, as needed. In addition, policy review revealed qualified staff responsible for carrying out (residents') interventions specified in the care plan were to be notified of their roles and responsibilities regarding the interventions, initially and when changes were made. 1(a). Review of the face sheet for R7 revealed the facility admitted the resident on 12/19/2022, with diagnoses of atherosclerotic heart disease, chest pain, diabetes mellitus, chronic kidney disease, and contractures of left hip, right knee, and left knee. Review of the Quarterly Minimum Data Set (MDS) Assessment for R7 dated 07/27/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, meaning R7 had intact cognition. Review of the Comprehensive Care Plan for R7 dated 12/22/2022, revealed the facility developed a problem for Respiratory/Pulmonary related to nicotine dependence with cigarettes. Continued review revealed on 05/29/2023, the facility noted R7 was to be free from injuries related to unsafe smoking practices with approaches (interventions) that included educating the resident about smoking risks and hazards. Further review revealed additional approaches included educating the resident and/or responsible party of the facility's policy on smoking locations, times, and safety rules. During observations on 07/30/2024 at 3:20 PM; 07/31/2024 at 10:55 AM; and 08/01/2024 at 9:22 AM, R7 was observed in his room with an opened pack of cigarettes and a lighter either lying on his overbed table or on his bed. Continued observation revealed a lock box sitting on the bedside table. In interview, on 08/01/2024 at 9:22 AM, R7 stated, when asked about the lock box, it was for his cigarettes and lighter to be stored in. In addition, R7 further stated he was about to go out and smoke and he had just taken the cigarettes and lighter out of the lockbox. However, the State Survey Agency (SSA) Surveyor had observed R7 in the smoking area prior to the interview. 1(b). Review of the face sheet for R48 revealed the facility admitted him on 05/06/2022, with diagnoses of chronic obstructive pulmonary disease (COPD), acquired absence of right and left legs below knees and personality disorder. Review of the Quarterly MDS assessment dated [DATE] revealed the facility assessed R48 to have a BIMS score of 14 out of 15 which indicated the resident was cognitively intact. Review of the Comprehensive Care Plan for R48 dated 06/12/2022, revealed the facility noted under the category of Activities of Daily Living (ADLs) Functional Status/Rehabilitation Potential the resident was an independent smoker dated 06/12/2022. Continued review revealed a goal target date of 08/29/2024 revealed a goal for R48 to not suffer injury from unsafe smoking practices through the next review date. Further review revealed approaches included on 06/12/2022 to instruct R48 on the facility policy regarding smoking locations, times, and safety. Additional review revealed an approach start date of 06/12/2022, noting R48 might smoke unsupervised, with a last reviewed/revised date of 07/18/2024. During observations of R48 on 07/30/2024 at 3:04 PM; 07/31/2024 at 10:40 AM; and 08/01/2024 at 1:33 PM, the resident was observed sitting on his bed with cigarettes and lighter lying either at the end of the bed or on his overbed table. In interview at 07/30/2024 at 3:04 PM and 08/01/2024 at 1:33 PM, R48 stated he was going out to smoke soon or had just returned from smoking were the reasons given for him not having the lighter and cigarettes stored in the locked box. During an interview with the Activities Director (AD) on 08/01/2024 at 9:57 AM, regarding the smoking policy and residents keeping a lock box with cigarettes and lighters in their rooms, she stated the lock boxes had been in residents' rooms for a few years. She stated it was her responsibility to ensure the residents had cigarettes to smoke during their smoke breaks. The AD stated R7 and R48 were independent smokers and were able to smoke whenever they wanted; however, they had also been observed to smoke in restricted areas like the front of the building and in the vending machine area. She further stated she also developed residents' comprehensive care plans related to smoking and should have included the lock boxes for their smoking paraphernalia on their care plans. In an interview conducted with the MDS Coordinator on 08/01/2024 at 3:45 PM, she stated the Activities Director usual responsibility was to develop the residents' smoking care plans. She also stated however, it was my responsibility to ensure it (smoking) was on the residents' care plans. The MDS Coordinator further stated she was unaware of the locked boxes in the residents' rooms used for storage of their cigarettes and lighters. In an interview on 08/01/2024 at 5:32 PM, the Administrator and DON stated they were unaware the residents' care plans did not reflect the lock boxes being used as an approach for safety. 2. Review of R14's Face Sheet, revealed the facility admitted the resident on 11/04/2022, with diagnoses to include; hereditary spastic paraplegia, Parkinson's Disease with dyskinesia, and multiple sclerosis. Review of the Annual MDS assessment dated [DATE], revealed the facility assessed R14 to have a BIMS score of 15 out of 15, indicating the resident was cognitively intact. Continued review of the MDS revealed the facility also assessed R14 as dependent on staff for transfers. Review of R14's Comprehensive Care Plan dated 11/11/2022, revealed the facility had developed a focus problem related to Activities of Daily Living (ADL's), self-care performance deficit related to impaired mobility. Continued review revealed an intervention dated 11/11/2022, for R14's transfers with assist of two staff and use of a mechanical lift. Observation on 07/29/2024 at 6:50 PM, State Surveyor Agency (SSA) Surveyor observed Certified Nursing Assistant (CNA) 17 enter R14's room with a mechanical lift. The SSA Surveyor waited 4-5 minutes and entered R14's room and observed R14 lying on the bed and CNA 17 was moving the lift away from the bed. Further observation revealed no other staff present in R14's room therefore, CNA 17 had utilized the mechanical lift alone when transferring R 14 to bed. Review of the Resident Profile (the facility's CNA Care Guide) dated 11/11/2022, revealed R14 required assistance of two staff members and use of a mechanical lift for transfers. In an interview with R14 on 07/29/2024 at 7:00 PM, he stated that had not been the first time only one staff member had transferred him with the lift onto his bed. He stated he was unsure how many staff were to transfer him. R14 further stated sometimes it was two people and sometimes it was only one person. In an interview with CNA 17 on 07/29/2024 at 6:55 PM, she stated R14 required assist of two staff and the mechanical lift for transfers. She stated she had not been able to find anyone to help her put R14 to bed. CNA 17 stated there had been another aide on the floor, but she was assisting residents on another hall. She stated there was a nurse on the unit; however, she had not asked the nurse for help. CNA 17 further stated it was important to follow R14's care plan as the mechanical lift could tilt and the resident could sustain a fall. In an interview with the DON on 08/01/2024 at 2:24 PM, she stated she expected staff to follow the residents' care plans and ensure residents' safety. She further stated by not following the care plan CNA 17 had not ensured R14's safety. In an interview with the Administrator on 08/01/2024 at 7:29 PM, she stated she was not clinical; however, she expected nursing staff to follow the facility's policies and follow residents' care plans. She stated the care plan directed staff on how to care for the residents. The Administrator stated nurses were to ensure residents' care plans were followed and that outcomes would be different for each resident. She stated R14's safety was why two staff were used. The Administrator stated CNAs had access to the residents' care guides Matrix (charting system) and were educated to review and chart on residents on a daily basis. She further stated overall she expected staff to follow the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of facility policy, it was determined the facility failed to enter wound treatment orders upon receipt of the orders for two of 25 sampled residents (R)237 and R99. The findings include: Review of the facility policy titled, Clean Dressing Change dated 03/12/2024, revealed It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Further review revealed Physician's orders were to specify the type of dressing and frequency of changes. 1. Review of R237's record revealed the facility admitted the resident on 07/25/2024, from an acute hospital setting, with diagnosis that included a Stage 4 pressure ulcer of the sacrum; other pulmonary embolism (blood clot blocking artery in the lung) with acute cor pulmonale (type of acute right side heart failure), and unspecified severe protein calorie malnutrition. Review of the Brief Interview for Mental Status (BIMS) assessment revealed the resident was severely cognitively impaired as evidenced by a score of five out of 15. Review R237's acute Continue Care Hospital document titled, Patient Discharge Instructions and Treatment Form dated 07/25/2024, for R237 revealed Wound Care instructions for the sacrum wound and left heel. Continued review revealed the sacral wound care instructions included a wound vac (vacuum) to be changed three times a week and wound care instructions for the left heel and wound prevention for the bilateral heels. Review of the admission Observation information for R237 dated 07/25/2024 at 5:50 PM, revealed it noted the presence of a Stage 4 ulcer of the resident's coccyx/sacrum and redness of the left heel. Review of the Wound Management Detail Report for R237 completed 07/26/2024 at 12:31 PM, revealed the resident had a pressure ulcer on sacrum. Per review, a Corrected Wound Edit History on 07/30/2024 at 9:38 AM, for R237 noted the wound to be a Stage 4 with measurements documented. Review of the Date of Service Progress Note for R237 dated 07/29/2024, the documented by the Advanced Practice Registered Nurse (APRN) revealed in the Assessment / Plan for staff to Continue wound vac from hospital. Review of the 07/25/2024 Progress Note at 18:53 for R237, revealed it read, Has a large open area on coccyx to have wound vac applied. Review of the Progress Notes dated 07/26/2024 at 6:42 AM, and 07/27/2024 at 6:32 AM revealed no documented evidence of a wound treatment in the notes. Review of the Progress Note entered on 07/27/2024 at 3:20 PM, revealed dressing changed to coccyx/sacrum and remains excoriated along peri wound. Silicone sacral dressing applied. Review of the Progress Note documented on 07/28/2024 at 2:26 PM, revealed the dressing to R237's coccyx/sacrum C/D/I (clean, dry, and intact) at that time. Additional review of the Progress Notes revealed no documented evidence of the wound vac being applied. Review of the Daily Skilled Service nursing note for R237 dated 07/25/2024 at 6:11 PM, revealed documentation for Skin and Wound Management noted as Wound Vac to Coccyx. Review of the Daily Skilled Service Observation documentation on 07/27/2024 at 3:32 PM for R237 revealed wound care treatment with no documented details of what treatment was performed. Review of an additional Daily Skilled Service Observation note entered on 07/28/2024 at 2:30 PM, revealed Skin and Wound Management Interventions were in place with no details of the treatment services provided. Further review of the Daily Skilled Service Observation notes revealed no documented evidence of the wound vac having been applied as per Physician's orders. Review APRN 20's Healing Partners Visit note dated 07/30/2024, revealed an assessment of the resident's wound characteristics was completed, the wound debrided (the process of removing dead skin and foreign material from a wound). Further review revealed a new recommendation and order for Dakin's (an antimicrobial solution) gauze and cover with bordered gauze to be completed twice a day. Review of R237's Medication Administration Summary for 07/01/2024 through 07/30/2024, revealed no documentation noting treatment orders addressing the resident's wound on the sacrum or heel, nor of treatment having been performed to the wound. Review of all orders for R237, both active and inactive, for the time period of 07/01/2024 through 07/30/2024, revealed no wound care orders for the resident's sacral wound until 07/30/2024 (five days after the resident's admission) at 5:35 PM, when an order was entered for Dakin's solution 0.125% gauze with bordered gauze to be completed twice a day as ordered. In an interview with Licensed Practical Nurse (LPN) 5 on 07/31/2024 at 3:32 PM, she stated she was not aware of the treatment orders from the referring facility (acute hospital) for R237. She stated she did not recall seeing anything in R237's paperwork about his wounds. The LPN stated she had measured the wound the day after his admission and a wet to dry dressing was in place at that time with a border gauze over it. LPN 5 said she did not recall if that dressing had been dated or not. She stated she had observed redness around the wound and stated she recalled there was tunneling (when a wound extends deeper into the tissue than its surface, creating a channel or tunnel) of the wound, but was not sure if there had been undermining (when significant erosion occurs underneath the visible wound margins resulting in more extensive damage beneath the skin surface). Per LPN 5's interview, she was told from the nurse who had been assigned to care for R237 to apply a normal saline wet to dry dressing to the wound. She stated she did not recall if she documented the dressing change though in R237's electronic medical record (EMR) or not. The LPN stated she had not seen R 237's wound since she assessed the wound the day after his admission. She further stated she did not know if there was a facility protocol for wounds and verbalized if a resident did not have an order, the nurse should call the Medical Doctor or the Nurse Practitioner for orders. In an interview with the admitting nurse, LPN 6 on 07/31/2024 at 3:56 PM, she stated she received report from the referring facility (acute care hospital), but had written her notes on regular paper. LPN 6 stated she had not seen a paper from the referring facility with wound care instructions on it. She stated there was another nurse assisting with putting in the orders for R237's admission, and she had not known the ancillary orders were not entered. The LPN stated she asked the medical APRN about a dressing order, but the APRN did not feel comfortable giving her an order. Per LPN 6's interview, she did not know who first put a normal saline wet to dry dressing on R237's wound, and she did not return to work again until the following Thursday. She further stated the wound vac had been available in R237's room at the time of his admission and she asked the nurse who relieved her to apply the wound vac. LPN 6 additionally stated she did not know why the wound vac was not placed. In an interview with LPN 9 on 07/31/2024 at 4:20 PM, she stated she made rounds with the wound APRN as well as worked as a floor nurse. LPN 9 stated she was not there the day R237 came in, but worked on the floor the weekend after his admission. She stated she recalled placing a wet to dry dressing on R237's wound during her shifts as she had been assigned the resident. The LPN said she had received the instruction in report and stated she was asked to talk to the wound APRN on Tuesday when the APRN made rounds at the facility. LPN 9 stated she just charted in the nurse's notes or observation documentation that the wound care was done. She went on to say that Medical Director 19 delegated the wound care to the wound APRN. LPN 9 further stated R237's wound looked about the same on Tuesday as it had when she cared for the resident as the assigned nurse the previous weekend. In an interview on 08/01/2024 at 9:45 AM, with Medical Doctor 19, he stated he was the Physician for R237. He stated he was aware R237 had been admitted with a Stage 4 wound to the coccyx. The Medical Director stated he recalled a nurse contacted him regarding the peri wound status and the wound vac not having been placed as ordered. He stated he recalled giving the order to apply a saline wet to dry dressing until the wound APRN saw R237 on Tuesday; however, did not recall who contacted him. He further stated the wound APRN recommendations were to be implemented as orders and he expected nursing staff to contact him if there was a question or concern. In an interview with the Regional Resource Nurse (RRN) on 08/01/2024 at 8:25 AM, the RRN produced a timeline validating wound care was provided for R237. The RRN verified the order had not been entered. During the interview, RRN also provided documentation of education initiated on 07/31/2024, addressing the necessity of entering an order into the facility's Matrix Electronic Medical Record (EMR) MATRIX. Per the RRN's interview, the educational inservice titled, MD Order was initiated on 07/31/2024 for all licensed staff related to the person receiving treatment orders, as well as verifying the treatment on the TAR in MATRIX prior to performing the treatment. 2. Review of R99's medical record revealed the facility admitted the resident on 02/17/2024, with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD); aspiration pneumonitis; Chronic Kidney Disease, Stage 4 (severe); and chronic systolic (congestive) heart failure. Review of the admission MDS assessment dated [DATE], revealed the facility assessed R99 to have a BIMS score of 12 out of 15 indicating the resident was cognitively intact. Review of the 02/17/2024 admission Assessment information revealed the presence of a wound on R99's coccyx and foot; however, with no orders entered for treating those skin areas. Per record review, R99 had been by the Wound Care APRN on 02/22/2024 with treatment orders given. Review of R99's February and March 2024 Physician orders and Treatment Administration Record (TAR) revealed no orders noted for wound care until mid-March. Review of the weekly Wound APRN Notes dated 03/07/2024 through 03/28/2024, revealed R99's wounds were improving week - to - week. In interview on 08/01/2024 at 6:08 PM, the former Unit Manager/LPN 4 (UM/LPN 4) stated she personally completed the treatments for R99 every day, including on the weekend because she had been on-call. She stated she also completed the treatments because she took special interest in R99 due to knowing the resident's daughter. Former UM / LPN4 further stated she used to be the wound care nurse and had a great memory for treatment orders and had been very active and involved in the care of the residents on her unit. In an interview with the Director of Nursing (DON) on 08/01/2024 at 03:10 PM, DON stated it was her expectation that orders would be entered on the same day they are received. In an interview with the Administrator on 08/01/2024 at 06:30 PM, the Administrator stated it was her expectation that orders were entered into the EMR and expected nurses to follow the orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility policy, the facility failed to have an effective system in place to ensure residents' safety and adequate supervision was provided to prevent accidents related to smoking in prohibited areas and smoking paraphernalia not being kept in secured locations for three residents (R) 7 and R48) out of twenty-five total sampled residents. R48 was observed smoking in a prohibited area, and R7, R14, and R48 were all observed with smoking paraphernalia lying on their beds and bedside tables and not secured in the bedside lockbox provided as required. In addition, the facility failed to ensure staff utilized a mechanical lift (as required) during transfer of R14. The findings include: Review of the facility policy titled, Accidents and Supervision dated 01/02/2020, with a revision date of 02/21/2024, revealed the resident environment was to remain as free of accident hazards as was possible, and they were to receive adequate supervision and assistive devices to prevent accidents. Continued review revealed ensuring adequate supervision and assistive device to prevent accidents included: identifying hazards and risks; evaluating and analyzing hazards and risks; implementing interventions to reduce hazards and risks and monitoring effectiveness; and modifying interventions when necessary. Review of the facility policy titled, Resident Smoking dated 03/2020, revised 05/20/2024, revealed, it was the policy of the facility to provide a safe and healthy environment for residents including safety as related to smoking. Per policy review, smoking was prohibited in all areas except the designated smoking area. Continued review revealed a Designated Smoking Area sign was to be prominently posted. Further review revealed the safety measures to be provided included a designated smoking area to be located away from exits and a common space to be utilized to protect non-smoking residents from second-hand smoke. In addition, review revealed all smoking materials were to be maintained in a secure location either with the resident or with facility staff. 1(a). Review of the face sheet for R7 revealed the facility admitted the resident on 12/19/2022, with diagnoses of atherosclerotic heart disease, chest pain, diabetes mellitus, chronic kidney disease, and contractures of left hip, right knee, and left knee. Review of the 07/27/2024 Quarterly Minimum Data Set (MDS) Assessment for R7 revealed the facility assessed him to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating he was cognitively intact. Observation of R7 on 07/30/2024 at 3:20 PM, revealed him in his room with an opened pack of cigarettes and a lighter lying on the overbed table. Per observation, a lock box was sitting on the resident's bedside table. When questioned regarding the lock box at the time of observation, R7 stated it was for storage of his cigarettes and lighter. He further stated he was about to go out and smoke and had just taken the cigarettes and lighter out of the lockbox. R7 said he was aware his cigarettes and lighter were to be locked in the lock box when not in use. However, during an earlier observation of the resident by the State Survey Agency (SSA) Surveyor, R7 was observed in the smoking area. In an observation and interview on 07/31/2024 at 10:55 AM of R7, the resident was in his room with his cigarettes and lighter again sitting on the overbed table. He stated he had just returned from smoking and had not locked his cigarettes and lighter away yet. In additional observation on 08/01/2024 at 9:22 AM of R7, the resident was in his room with his cigarettes and lighter lying on the overbed table. R7 was watching television (TV), but stated he would be going out to smoke soon. 1(b). Review of the face sheet for R48 revealed the facility admitted him on 05/06/2022, with diagnoses that included chronic obstructive pulmonary disease (COPD), personality disorder, and acquired absence of right and left legs below knees. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed him to have a BIMS score of 14 out of 15, which indicated he was intact cognitively. Observation on 07/30/2024 at 3:04 PM, of R48 revealed he was in his room with cigarettes and a lighter lying on his bed, with a lock box sitting on the bedside table. He stated he was going out to smoke soon and that was why the cigarettes were out. R48 further stated he had been smoking most of his life and had smoked here since his admission, and knew the cigarettes and lighter were to be locked up. Observation on 07/31/2024 at 10:40 AM, of R48 revealed he outside on the smoking porch smoking. Continued observation at 10:55 AM, revealed R48 was back in his room with the cigarettes lying on the overbed table. The resident stated he had not had time to return the cigarettes to the lock box. Observation on 08/01/2024 at 1:33 PM, of R48 revealed him sitting on bed with his cigarettes and lighter at the end of the bed. R48 stated he would be going out to smoke soon. In interview on 08/01/24 at 9:57 AM, the Activities Director (AD) stated residents who were independent smokers, had a lock box to store their cigarettes and lighters in located in their rooms. She stated she knew there was a form the nurses filled out to assess residents in order for residents to independently smoke. In interview on 08/01/24 05:32 PM, the Director of Nursing (DON) and Administrator stated they were not aware of R48 smoking in a restricted smoking area. They stated if the residents doing that did not follow the policy, their smoking privileges would be revoked. In additional interview on 08/01/2024 at 5:40 PM, the Administrator stated she expected the residents to follow the facility's policy regarding smoking. In additional interview on 08/01/2024 at 5:55 PM, the DON she expected all residents to follow the facility's policies. She further stated those particular residents (R7 and R48) were difficult to manage regarding their smoking. 2. Review of the facility policy titled, Safe Handling/Transfers, dated 02/2024, revealed it was the facility's policy to ensure residents were handled and transferred safely to prevent or minimize risks for injury. Continued review revealed the facility's policy to provide and promote a safe, secure and comfortable experience for the resident in accordance with current standards and guidelines. Further review revealed all residents required safe handling when transferred to prevent or minimize the risk for injury to themselves and employees assisting them. Review of the Face Sheet for R14 revealed the facility admitted him on 11/04/2022, with diagnoses that included: multiple sclerosis, hereditary spastic paraplegia, and Parkinson's Disease with dyskinesia. Review of the Annual MDS assessment dated [DATE], revealed the facility assessed R14 to have a BIMS score of 15 out of 15 indicating he was intact cognitively. Additional MDS review revealed the facility also assessed the resident as dependent on staff for transfers. Review of the Comprehensive Care Plan for R14 dated 11/11/2022, revealed the facility had developed a focus problem for Activities of Daily Living (ADL's) due to self-care performance deficit related to impaired mobility. Review of the care plan further revealed intervention dated 11/11/2022, for R14 to be transferred with a mechanical lift and assist of two staff. Review of the 11/11/2022, Resident Profile (the Certified Nursing Assistant [CNA] Care Guide) revealed the facility noted R14 required assistance of two staff members and use of mechanical lift for transfers. Observation on 07/29/2024 at 6:50 PM, revealed CNA 17 enter R14's room with a mechanical lift with no other staff member present. Continued observation, after four to five minutes later, when the State Survey Agency (SSA) Surveyor entered R14's room, revealed the resident was lying on his bed and CNA 17 was moving the mechanical lift away from the bed. Further observation revealed no other staff present to have assisted with R14's transfer, therefore, CNA 17 had utilized the mechanical lift alone when transferring the resident. In interview on 07/29/2024 at 7:00 PM, R14 stated CNA 17's transfer of him alone, had not been the first time only one staff member had transferred him to bed. R14 further stated he was not sure how many staff were to transfer him, and sometimes it was two people and sometimes it was one person. In interview on 07/29/2024 at 6:55 PM, CNA 17 stated R14 required a lift and assist of two staff for transfers. CNA 17 stated she had not been able find anyone to help her transfer R14 to bed. CNA 17 said there had been another CNA, but that aide had been assisting on another hall. She stated a nurse had been on the unit, but she had not asked the nurse for help. The CNA also stated it was important to follow R17's care plan as the lift could tilt and the resident could fall. In an interview on 08/01/2024 at 2:24 PM, the DON stated CNA 17 had been sent home after being made aware R14 transferred R14 without using two staff (as required). The DON stated all staff were to ensure residents' safety and CNA 17, by not following R14's care plan and using two staff had not ensured the resident's safety. In an interview on 08/01/2024 at 7:29 PM, the Administrator stated she expected staff to follow the facility's policies and residents' care plans. The Administrator said residents' care plan directed staff on how to care for the resident. She stated R14's safety was why two staff were used and CNA's had access to residents' care guides in Matrix (charting system). The Administrator additionally stated she expected staff to follow the (residents') care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure drugs and biologicals were stored in accordance with the manufacturer's specifications and accepted professional nursing principles and practices for one (1) of two (2) medication rooms audited. Observation on [DATE] at 10:40 AM, of the medication room that serviced rooms on the facility's 100 and 200 halls revealed one (1) open and undated multidose vial of medication and sixty-two (62) wound care products that were beyond the expiration date printed on the label. The findings include: Review of the facility's policy titled, Medication Administration with a revision date of [DATE], revealed medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state .and in accordance with professional standards of practice in order to prevent contamination or infection. Further review revealed the person administering the medication was to, Identify the expiration date. If expired, notify nurse manager. Observation on [DATE] at 10:40 AM, of the medication room that served the 100 and 200 halls, revealed one (1) opened and undated bottle of Tubersol (an injectable solution used for testing for tuberculosis) available for use in the refrigerator. Continued observation revealed nine calcium alginate 12 rope dressing material (utilized for wounds) with an expiration date of [DATE]; 44-2 x 2 calcium alginate with silver dressing materials with an expiration date of [DATE]; nine 4 x 8 calcium alginate with silver sheets with an expiration date of [DATE]; and one (1) package of Promogran collagen matrix (also utilized for wounds) with a printed expiration date of [DATE], all available for use beyond the printed expiration date on the packaging. During an interview on [DATE] at 6:04 PM, with Licensed Practical Nurse (LPN) 10 and LPN 4, stated it was important to date all medications when opened, and not use them or other products beyond the expiration date, to avoid a potential inaccurate result, loss of potency, allergic or skin reactions. In an interview on [DATE] at 6:22 PM, the DON stated when opening a multidose medication, the vial was to be dated with the opened date and placed in to the refrigerator and tossed after 30 days. In an interview with the Administrator on [DATE] at 6:22 PM, she stated it was her expectation for staff to follow the facility's policies.

Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to maintain safe and sanitary infection control precautions during wound care for 1 of 3 residents sampled for wound care out of 25 totaled sampled residents, (R)237. The finding include: Review of the facility's policy, Infection Prevention and Control Program with a revision date of 02/01/2024, revealed the facility had established and maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment. Per review, the facility's infection prevention program was also to help prevent the development and transmission of communicable diseases and infections. Continued review revealed All staff were to assume all residents were potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Review of the facility's policy titled, Clean Dressing Change with a revised date of 03/12/2024, revealed it was the policy of the facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Record review revealed the facility admitted R237 on 07/25/2024, with a chronic Stage 4 wound to the sacrum. Review of R237's current Physician's orders revealed the wound care and dressing change orders were for Dakin's solution 0.125% (a topical antiseptic used to treat and prevent infections in wounds, burns, and other areas) wet to dry dressing and cover with a bordered gauze twice daily. Observation on 08/01/2024 at 11:20 AM, of wound care for R237, revealed Licensed Practical Nurse (LPN) 6 cleaned the overbed table, laid a clean barrier on the table, and placed the wound care supplies onto the clean barrier. Continued observation revealed the wound care supplies included an unopened package of non-sterile 4 x 4's dressings, wound cleanser spray, the Dakin's solution, a bordered gauze dressing and a non-sterile cup. Per observation, LPN 6 washed her hands and donned a gown and gloves. Observation revealed LPN 6 proceeded with the wound care procedure and cleansed the wound with the wound cleansing spray and patted the wound bed with a non-sterile gauze she had laid onto the clean barrier. LPN 6 was then observed to discard the used 4x4 into a waste bag; however, without changing gloves, the LPN removed additional non-sterile 4x4's dressings from the non-sterile 4 x 4 package. Further observation revealed LPN 6 then applied the secondary bordered gauze dressing and removed her gloves and performed hand hygiene. In interview on 08/01/2024 at 11:55 AM, LPN 6 stated she was not aware she had reached into the 4x4 package with a used glove. LPN 6 was then observed to remove the 4x4 dressing package from the treatment cart. In interview on 08/01/2024 at 3:59 PM, Staff Development Coordinator (SDC) 2 revealed staff were educated annually through the competency skills fair regarding infection control and wound care. SDC 2 stated competency skills were completed through observation of staff performing the task utilizing a mannequin. The SDC stated staff were evaluated and educated during the observation. SDC 2 further stated the competency skills fair would be completed in the near future. In interview on 08/01/2024 at 6:30 PM, the Administrator stated it was her expectation staff followed the facility's policies.

Based on observation, interview, review of facility policy, and review of the FDA Food Code 2022 the facility failed to thaw, store, label and date food in accordance with professional standards for food service safety. Observation revealed meat thawing in sinks, meat on a tray out at room temperature (temp). Additionally, observation revealed expired and/or outdated food in the walk in cooler. The findings include: 1. A policy on thawing of frozen foods was requested from the Dietary Manager on 07/31/2024; however, such policy was not received. Review of the FDA Food Code 2022 Chapter 3. Food, Chapter 3-3-501.13 Thawing, revealed the time/temperature control for safety was that food should be thawed (A) Under refrigeration that maintains the FOOD temperature at 5oC (41oF) or less Pf; or (B) Completely submerged under running water . Observation on 07/30/2024 at 11:14 AM, during the initial kitchen tour, revealed in one of the sinks of the three compartment sinks were three thawing packaged whole pork loins. Continued observation revealed in another sink area a large roll of ground beef was lying on a tray. In an interview with the [NAME] on 08/01/2024 at 3:18 PM, she stated she had been employed at the facility for six months. She stated meat was to be thawed in the cooler on the lowest shelf and on a tray for food safety. The [NAME] further stated frozen meat was not to be thawed at room temperature. During an interview with the Dietary Manager (DM) on 07/30/2024 at 11:25 AM, she stated the pork loin and ground beef should have been placed on a tray and thawed in the cooler for food safety. She stated meats were not to be thawed in the sink or at room temperature. In an interview with the Administrator on 08/01/2024 at 7:29 PM, she stated kitchen staff were expected to follow policy and procedure when thawing meats; however, she did not know what the facility policy was. In an interview with the Regional Director of Operations (RDO) on 08/01/2024 at 8:01 PM, she stated all staff had been educated on thawing meats on the bottom shelf in the walk-in (cooler) or under cool running water. 2. Review of the facility policy titled, Food storage, Cold, undated, revealed it was policy to ensure all time/temperature control for safety, frozen and refrigerated food items be appropriately stored in accordance with guidelines of the FDA Food Code. Continued review revealed the dining service director or cook were to ensure all food items were stored properly in covered containers labeled and dated and arranged in a manner to prevent cross contamination. Observation of walk in cooler on 07/30/2024 at 11:14 AM, revealed the following items were expired/outdated: a large plastic container 1/4 full of sliced peaches dated 07/18/2024; a small container 1/4 full of pears with white green substance undated; a jar with 4 whole boiled eggs that were brown in color, dated 07/14/2024; a large container 3/4 full of Parmesan cheese dated 07/09/2024; a plastic container of banana pudding dated 07/14/202; a bag 1/4 full of shredded cheese dated 07/18/2024; and a small container of bacon grease dated 07/07/2024. During continued interview with the DM on 07/30/2024 at 11:25 AM, she stated she had been on vacation last week and the cooks had been responsible for checking the coolers (for expired/outdated food) while she was off. The DM stated all staff had been educated on food storage and signs were all over the kitchen to remind staff to label and date all items. She further stated staff had also been educated on checking the coolers on a daily basis. In an interview with the [NAME] on 08/01/2024 at 3:18 PM, she stated she had been employed at the facility for 6 months. The [NAME] stated all items were to be labeled and dated before storing in the coolers. She stated items stored were good for three days once opened. She stated the morning cook was supposed to check the cooler daily for items that were out of date. She further stated the evening cook was to check at the end of the shift. In an interview with the Regional Director of Operations (RDO) on 08/01/2024 at 8:01 PM, she stated she expected staff to label and date all items prior to putting them in the walk-in cooler. She stated all staff had been educated on doing that. She stated the managers and cooks were to check the coolers in the morning when opening the kitchen and in the evening when closing the kitchen. In an interview with the Administrator on 08/01/2024 at 7:29 PM, she stated the kitchen staff were expected to follow policy and procedures on labeling and dating food items before placing them in the walk-in cooler. She further stated she expected staff to check for expired food items and dispose of them if not within the appropriate date.

Based on observation and interview the facility failed to ensure garbage was stored appropriately and covered, away from food preparation (prep) areas in the kitchen. Observation revealed a large, uncovered trash receptacle almost full of trash, which was stored approximately four steps away from the food prep area. The findings include: During an interview with the Dietary Manager on 07/30/2024 at 11:25 AM, she stated she expected the staff to keep the trash bins covered and away from the food prep area. Observation on 07/30/2024 at 11:14 AM, revealed a large, uncovered trash receptacle ¾ full of trash stored approximately four steps away from the food prep area in the kitchen. In an interview with the [NAME] on 08/01/2024 at 3:18 PM, she stated trash bins should always be covered. She further stated the trash bins should not have been stored that close to the food prep area. In an interview with the Dietary Manager (DM) on 07/30/2024 at 11:25 AM, she stated the trash bins should have been stored in a corner area of the kitchen and away from the food prep area. She further stated the bins should have been covered at all times. In an interview with the Regional Director of Operations (RDO) on 08/01/2024 at 8:01 PM, she stated she expected staff to ensure the trash bins were moved away from the food prep areas. In addition, she stated she expected staff to always keep the trash bins covered. In an interview with the Administrator on 08/01/2024 at 7:29 PM, she stated her expectation was that the trash containers be covered and moved away from any area where food was being served or prepared.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, it was determined the facility failed to maintain clinical records in accordance with accepted professional standards for one of three (3) sampled residents (Residents #6). Review of Resident #6's Medication Administration Record (MAR) revealed staff failed to document that the resident received seventeen doses of Norco (Hydrocodone 5, Acteaminophen 325), from 09/27/2023 through 10/28/2023 on the MAR. However, only two doses of the medication were signed out on the Medication Administration Record (MAR). The findings include: Review of the facility's policy, Medication Administration, dated 11/01/2023, revealed that medications were administered by licensed nurses or other staff who were legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. Continued review revealed that staff would sign the medication administration record (MAR) after the medication was administered Closed record review revealed the facility admitted Resident #6 to the facility on [DATE] with diagnoses which included Unspecified Convulsions, Dysphasia and Aphasia. Further review of the record revealed Resident #6 was discharged on 11/15/2023. Review of Resident #6's Quarterly Minimum Data Set (MDS) Assessment, dated 10/26/2023, revealed the facility assessed to resident to have a Brief Interview for Mental Status (BIMS) score of zero (0) indicating the resident was rarely understood. Review of Resident #6's Narcotic Control Record, revealed from 9/27/2023 through 10/28/2023, Resident #6 had seventeen (17) doses of Norco (Hydrocodone 5 Acetaminophen 325) signed out. However, review of the Medication Administration Record (MAR) dated 09/27/2023 through 09/30/2023 and [DATE]/01/2023 through 10/28/2023, revealed that only two (2) doses of Norco had been signed out on the medication administration record (MAR). Interview with Licensed Practical Nurse # 1 on 11/22/2023 at 6:38 AM, she stated the MAR and the narcotic control logs are supposed to match. She stated she should have signed out Resident #6's medication on the MAR when it was administered. In an interview with the Director of Nursing (DON), on 11/21/2023 at 3:45 PM, she stated on 11/08/2023 staff caught Resident #6's spouse trying to get access to the medication cart to review the narcotic book. She stated Resident #6's spouse told her the MAR was blank and she knew Resident #6 had received pain medication. The DON stated she audited Resident #6's MAR/Narcotic record and discovered licensed staff were only signing the narcotic book and not documenting on the MAR. During an interview with the Administrator on 11/22/2023 at 12:00 PM, she stated the DON had made her aware that Resident #6's spouse had seen a copy of the MAR and it was blank. She stated they immediately started an investigation and discovered some of the nurses were not signing the MAR when administering PRN medication. She stated on 11/08/2023, she, the DON and the Medical Director held an ad hoc telephone call to discuss staff not signing the MAR after medication administration. *The facility implemented the following actions to correct the deficient practice: 1. On 11/08/2023 the Director of Nursing was made aware that licensed nurses and medication aides were not documenting the administration of as needed controlled drugs in the electronic health record. 2. On 11/08/2023, current residents that received PRN medications were reviewed by the DON and/or Assistant Director of Nursing (ADON). 3. On 11/08/2023 licensed staff and medication aides were educated by the DON that all controlled medications must be signed out on the narcotic sheet and in the electronic medical record (EMR) on the medication administration record (MAR). 4. On 11/09/2023 the facility initiated random audits on 100, 200, 300 and 400 halls, one resident daily from each hall, that were ongoing and would continue for twelve (12) weeks and the results would be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for review and documentation recommendation. The next QAPI meeting was scheduled for the week of 11/27/2023. 5. On 11/08/2023, an Ad HOC Quality Assurance (QA) with the Medical Director, Administrator, and DON was held. The purpose of the Ad HOC meeting was to discuss the outcomes of the medication administration audit conducted on 11/8/2023 by the DON and to ensure staff were educated on signing out controlled drugs in the HER (electronic health record). **The State Survey Agency Validated the corrective action by the facility as follows: 1. In an interview with the Director of Nursing (DON), on 11/21/2023 at 3:45 PM, she stated Resident #6's spouse told her on 11/08/2023, that the MAR was blank, and she knew Resident #6 had received pain medication. She stated she audited Resident #6's MAR/Narcotic record and discovered licensed staff were not signing the MAR, only the narcotic book. 2. Interview with the DON on 11/21/2023 at 3:45 PM, she stated on 11/08/2023, she and the Unit Manager completed MAR audits on all current residents receiving PRN pain medication. 3.Interviews with Kentucky Medication Aide (KMA) #1 on 11/21/2013 at 4:02 PM, the Staff Development Coordinator (SDC) on 11/21/2023 at 4:15 PM, Licensed Practical Nurse (LPN) #1 on 11/22/2023 at 6:38 AM, KMA #2 on 11/22/2023 at 11:00 AM, and LPN #2 on 11/22/2023 at 11:25 AM, revealed they had been educated recently by either the DON/Unit Manager on signing out PRN medication in the EMAR (Electronic Medication Record) and on the narcotic control logs. 4. Review of the Audit for MAR Documentation, revealed the Unit Manager conducted audits of the Medication Records. Audits were initiated on 11/09/2023 and were ongoing as of 11/22/2023. Audits would continue for 12 weeks and results forwarded to the QAPI committee for review. 5. Review of Attendance Rosters, dated 11/08/2023, revealed the facility had an Ad HOC meeting with the Medical Director, Administrator, and DON on 11/08/2023. During an interview with the Administrator on 11/22/2023 at 12:00 PM, she stated she and the DON notified the Medical Director and had a telephone meeting to discuss the licensed staff signing the MAR after administering medications. In an interview with the Medical Director on 11/22/2023 at 12:40 PM, he stated he received a call from the Administrator and as Ad HOC QAPI meeting was held via telephone on 11/08/2023, to discuss the nurses not signing out medications in the EMR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately. However, not later than two (2) hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury for one (1) out of five (5) sampled residents, Resident #3. On [DATE], Resident #3 was noted to have bruising and increased pain to his/her right knee. An X-ray of the right knee was performed on [DATE], and review of the X-ray report dated [DATE] at 5:40 AM, revealed Resident #3 had an acute distal femur fracture with malalignment. However, there was no documented evidence the facility reported the injury incident as an injury of unknown origin. The findings include: Review of the facility policy, Abuse, Neglect, and Exploitation, dated [DATE] and revised on [DATE], revealed it was the policy of the facility to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibited and prevented abuse, neglect, exploitation, and misappropriation of resident property. Continued review revealed on reporting and response the facility was to have written procedures that included reporting all alleged violations to the Administrator, State Agency, Adult Protective Services (APS) and to all other required agencies within the specified time frames immediately, but not later than two (2) hours after the allegation was made if the events that caused the allegation involved abuse or resulted in serious bodily injury. Further review revealed reporting should not be later than twenty-four (24) hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury. Review of the closed medical record for Resident #3 revealed the facility admitted the resident on [DATE], with diagnoses that included: Dementia, Unspecified; Unilateral Primary Osteoarthritis, Unspecified Knee; Osteomyelitis Unspecified; and Difficulty in Walking. Continued review revealed Resident #3 was admitted to Hospice Care on [DATE] and expired in the facility on [DATE]. Review of the Significant Change of Status Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #3 to have a Brief Interview for Mental Status (BIMS) score of one (1) indicating the resident had severe cognitive impairment. Continued review of the MDS Assessment, section G, Activities of Daily Living (ADL) revealed the facility assessed Resident #3 to require limited assist of one (1) staff for transfers; supervision of one (1) staff member for walking in his/her room; and as independent with no supervision required when walking in the corridor. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of two (2) indicating he/she continued to have severe cognitive impairment. Continued review of MDS Assessment, section G, ADL, revealed the facility assessed Resident #3 to require extensive assist of two (2) staff for transfers; and walking in the room and corridor, coded as an eight (8) which indicated the activity did not occur. Review of the Progress Note dated [DATE] at 9:52 AM, signed by Licensed Practical Nurse (LPN) #1 revealed Resident #3 complained of pain to his/her right knee, ankle and foot area. Further review revealed LPN #1 also noted Resident #3's right knee was bruised. Review of the Progress Note dated [DATE] at 3:16 PM, signed by LPN #1 revealed a new order was received from Hospice to obtain an X-ray of Resident #3's right knee due to increased pain and swelling with bruising. Review of the X-ray imaging report dated [DATE], revealed the X-ray resulted at 5:40 AM, noted the results were fracture of the distal femoral shaft with malalignment joint space narrowing and mild soft tissue swelling. Further review revealed the conclusion was an acute appearing femoral fracture. Review of the Progress Note dated [DATE] at 8:55 PM, but created on [DATE], by the former Director of Nursing (DON) revealed she spoke with Resident #3's Power of Attorney (POA) regarding the X-ray results which noted the fracture to the resident's right femur. Continued review revealed the POA agreed the cause was from Resident #3 self-transferring or his/her spouse attempting to transfer the resident. Per review, Resident #3's right leg had a history of issues and integrity was compromised due to the multiple infections of the right knee and multiple surgeries. Further review revealed Resident #3 had a history of Osteoarthritis, Osteomyelitis, and Osteopenia. Further review revealed the POA voiced appreciation for the follow up and expressed that she did not want any surgical intervention, and the facility should focus on keeping the resident comfortable. Review of the History and Physical (H&P) dated [DATE], completed by the attending Physician revealed Resident #3 was under Hospice care; had a right femur fracture, pathological due to long term Prednisone use; and painful movement. Continued review of the H&P revealed the Physician noted Resident #3 had chronic pain syndrome for which he/she received Morphine and Norco (both narcotic pain medications). Per review, Resident 33 had Vascular Dementia worsening with sundowners (confusion, restlessness, agitation, and disorientation occurring in the late afternoon and lasting into the night). Further review revealed Resident #3 had Remeron (antidepressant medication) for depression and anxiety. Review further revealed due to Resident #3's femur he/she was bedridden, and was to continued to receive Hospice care and pain control. In addition, the Physician noted Resident #3's condition poor and prognosis were poor. In an interview on [DATE] at 5:33 PM, the former DON stated the Progress Note she documented as [DATE] was not documented by her until [DATE]; however, she did not enter the Note as a late entry. She stated the facility did not perform an investigation of Resident #3's injury of unknown origin, nor report the femur fracture as such. The DON further stated the Physician said the fracture was pathological in nature and therefore she did not document or report the fracture. During an interview on [DATE] at 1:28 PM, the current DON stated she had been the DON at the facility for approximately thirty (30) days. She stated her expectation was that any injury of unknown origin be investigated and reported as required. The DON stated she was not here at the time and could not speak to whether or not an investigation happened in regard's to Resident #3's femur fracture. During an interview on [DATE] at 1:45 PM, the Administrator stated she had been at the facility since [DATE], and had been a Licensed Nursing Home Administrator (LNHA) for a year. She stated she was unsure about the facility's policy; however, she would seek counsel from the facility's corporate staff related to injuries of unknown origin being reported to the State Agency. The Administrator stated if an incident was truthfully an injury of unknown origin, then it should have been investigated and reported as such. She further stated the facility was required to investigate and report all alleged violations of abuse/neglect within two (2) hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of the facility's Abuse policy, it was determined the facility failed to conduct a thorough investigation concerning an injury of unknown origin which was diagnosed as a right distal femur fracture for one (1) of five (5) sampled residents reviewed for potential abuse, neglect and mistreatment, Resident #3. On [DATE], Resident #3 was noted to have bruising to his/her right knee and increased pain in the knee. An X-ray of the right knee was obtained on [DATE] and on [DATE] at 5:40 AM, the X-ray results noted Resident #3 had an acute distal femur fracture with malalignment. However, there was no documented evidence the facility investigated the incident as an injury of unknown origin. The findings include: Review of the facility policy, Abuse, Neglect, and Exploitation, dated [DATE] and revised on [DATE], revealed it was the facility's policy to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibited and prevented abuse, neglect, exploitation, and misappropriation of resident property. Continued review revealed an Alleged Violation, was a situation or occurrence that had been observed or reported by staff, residents, relatives, visitor, or others; however, had not yet been investigated. Per review, if the situation or occurrence was verified it could be indication of noncompliance with the federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Review revealed the Investigation of Alleged Abuse, Neglect and Exploitation, an immediate investigation was warranted if suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation, occurred. Per policy review, the written procedures for investigations included: investigating different types of alleged violations, identifying and interviewing all involved persons including the alleged victim, alleged perpetrator, and witnesses and others who might have knowledge of the allegation. Further review revealed the policy was noted as focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment had occurred, and providing complete and thorough documentation of the investigation. Review of the closed medical record for Resident #3 revealed the facility admitted him/her on [DATE], with diagnoses which included: Primary Unilateral Osteoarthritis, Unspecified Knee; Osteomyelitis, Unspecified; Difficulty in Walking; and Dementia, Unspecified. Continued review revealed Resident #3 was admitted to Hospice Care on [DATE] and was noted as deceased in the facility on [DATE]. Review of the Significant Change of Status Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #3 as having a Brief Interview for Mental Status (BIMS) score of one (1), indicating the resident was severely cognitively impaired. Continued review of the MDS Assessment, section G, Activities of Daily Living (ADLs) revealed the facility assessed the resident as requiring limited assistance of one (1) staff for transfers. Further review of section G revealed the facility also assessed Resident #3 to require supervision of one (1) staff person for walking in his/her room and as independent with no supervision required when walking in the corridor. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #3 as having a BIMS score of two (2), which indicated the resident as severely cognitively impaired. Continued review of section G, ADLs revealed the facility assessed the resident as requiring extensive assist of two (2) staff for transfers. Further review of section G, ADLs revealed the facility assessed Resident #3 as the activity of walking in his/her room and corridor as not occurring. Review of Resident #3's Progress Note dated [DATE] at 9:52 AM, signed by Licensed Practical Nurse (LPN) #1 revealed the resident complained of pain in his/her right knee, ankle and foot area, and his/her right knee was observed as bruised. Per review of the Note, Hospice Nurse/Registered Nurse (RN) #4, was at the facility and questioned Resident #3 about falling. Continued review revealed Resident #3 told Hospice Nurse/RN #4 he/she had not fallen. Further review revealed Hospice Nurse/RN #4 then asked if the facility Nurse Practitioner (NP) could assess Resident #3. Hospice Nurse/RN #4 and the facility's NP were both aware of the injured areas and assessed Resident #3. Review of the Progress Note dated [DATE] at 2:26 PM, documented by LPN #1 revealed Hospice Nurse/RN #4 was at the facility to see Resident #3 and had been made aware that the NP had ordered an X-ray of the resident's right foot and ankle due to pain in that area. Continued review revealed Hospice Nurse/RN #4 notified the Hospice Physician's nurse to request the next step to take regarding Resident #3's foot and ankle. Further review revealed the facility's NP had been made aware that Hospice would follow up with Resident #3's injury in the morning, and the facility's Director of Nursing (DON) was aware. Review of the Progress Note dated [DATE] at 3:16 PM, noted by LPN #1 revealed a new order had been received from Hospice to obtain an X-ray of Resident #3's right knee due to increased pain and swelling with bruising. Review of the X-ray imaging report dated [DATE] at 5:30 AM, revealed the X-ray results noted Resident #3 had a fracture of the distal femoral shaft with malalignment, joint space narrowing, and mild soft tissue swelling. Further review of the Report revealed the conclusion was noted as an acute appearing femoral fracture. Review of the facility's History and Physical (H&P) dated [DATE], completed by Resident #3's attending Physician revealed the resident was receiving Hospice care and had a right femur pathological due to long term steroid use. Continued review revealed the right leg was painful with movement, and Resident #3 had Chronic Pain Syndrome, which he/she had Morphine and Norco (narcotic pain medications) ordered for. Per review, the Physician noted Resident #3 had Vascular Dementia with worsening due to sundowners (agitation, confusion, restlessness, and disorientation occurring in late afternoon and lasting into the night). Further review revealed Resident #3 had Remeron (antidepressant medication) for diagnoses of depression and anxiety. Review further revealed the Physician noted Resident #3's Chronic Obstructive Pulmonary Disease (COPD) was stable with use of inhalers and medications. In addition, review of the H&P revealed Resident #3 had Osteoarthritis of the right knee, previous surgeries, old Osteomyelitis in right tibia, and history of patellar fracture non-operable, the resident's condition and prognosis were poor. In an interview with the former Director of Nursing (DON) on [DATE] at 5:33 PM, revealed she stated she could not speak to Resident #3's femur fracture as an injury of unknown origin as the Physician stated it was a pathological fracture. The DON stated the facility had not performed an investigation of the femur fracture as an injury of unknown origin. She further stated the Physician made rounds twice weekly in the facility; however, she was unable to say why there had been no documentation of the injury until [DATE], two (2) weeks following the fracture diagnosis. In an interview with the Administrator on [DATE] at 1:45 PM, she stated she had been a Licensed Nursing Home Administrator (LNHA) for a year, and had been at the facility since [DATE]. The Administrator stated she was unsure about the facility's abuse policy; however, would seek counsel from the facility's corporate personnel regarding if injuries of unknown origin were to be reported to the State. She stated if an incident was truthfully an injury of unknown origin, it should have been investigated. The Administrator additionally stated the facility was required to investigate all alleged violations of abuse or neglect within a two (2) hour timeframe.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, Centers for Medicare and Medicaid Services (CMS)Resident Assessment Instrument (RAI) Manual, and review of facility policy, it was determined the facility failed to review and revise a comprehensive person-centered care plan for two (2) of fourteen (14) sampled residents reviewed for care plans, Residents #2 and #3. Record review revealed Resident #2's care plan was not revised after he/she exhibited refusal and noncompliance with care. On [DATE] Resident #3 was noted with bruising to the right knee and increased pain. An X-ray of the right knee was performed on [DATE] and resulted on [DATE] at 5:40 AM and indicated Resident #3 had an acute distal femur fracture with malalignment. However, there was no documented evidence that the facility revised the comprehensive care plan when the fracture occurred. Record review revealed Resident #3's care plan was not revised after he/she sustained a right distal femur fracture on [DATE]. Review of the CMS RAI Manual, Section 4.7 The RAI and Care Planning, dated 10/2019, revealed the care plan was to be revised on an ongoing basis to reflect changes in the resident and the care that the resident required. The findings include: Review of the facility policy, Comprehensive Care Plans, dated [DATE], revealed it was the policy of the facility to develop and implement a comprehensive person centered care plan for each resident consistent with resident rights. Continued policy review revealed the comprehensive person centered care plan was also to include measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that had been identified in the resident's comprehensive assessment. Further review revealed the comprehensive care plan was to be reviewed and revised by the interdisciplinary team (IDT)after each comprehensive and quarterly Minimum Data Set (MDS) assessment. Review of the facility policy, Care Plan Revisions Upon Status Change, dated [DATE], revealed the purpose of the procedure was to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Review further revealed the comprehensive care plan was to be reviewed and revised as necessary when a resident experienced a status change. 1. Review of the closed record for Resident #3 revealed the facility admitted him/her on [DATE] with diagnoses that included: Difficulty Walking; Dementia, Unspecified; Unilateral Primary Osteoarthritis, Unspecified Knee; Osteomyelitis Unspecified. Review further revealed Resident #3 was admitted to Hospice Care on [DATE], and expired at the facility on [DATE]. Review of the Significant Change in Status MDS assessment dated [DATE] revealed the facility assessed Resident #3 to have a Brief Interview for Mental Status (BIMS) score of one (1) indicating he/she had severe cognitive impairment. Review of Resident #3's Comprehensive Care Plan dated [DATE], revealed the facility had developed a focus problem for pain, chronic, related to Osteoarthritis (OA). Per review, the care plan was reviewed by MDS Coordinator #1 on [DATE]. Continued review revealed the care plan contained the following interventions: administer medications as ordered; administer opioid reversal agent as ordered; observe and report changes in usual routine, sleep patterns; decrease in functional abilities. Review revealed the interventions also included: observing for decreased range of motion; withdrawal or resistance to care; observe, record, report to nurse any signs or symptoms of nonverbal pain, changes in breathing, vocalizations, mood or behavior, face or body changes. Further review revealed no documented evidence Resident #3's care plan was revised on or after [DATE], when Resident #3 sustained the right distal femur fracture. Review of the Progress Note dated [DATE], revealed Resident #3 complained of pain in his/her right knee, ankle and foot area. Review revealed Resident #3's right knee was bruised. Continued review revealed the Hospice Nurse/Registered Nurse (RN) #4, was at the facility on that date, and questioned Resident #3 about falling. Further review revealed Resident #3 told Hospice Nurse/RN #4 he/she had not fallen. During an interview on [DATE] at 11:44 AM, Licensed Practical Nurse (LPN) #2 stated she had received in report that Resident #3 had a right femur fracture. She stated she was not told how the fracture happened. The LPN stated Resident #3 often had pain and received routine and as needed pain medications. She further stated she would think Resident #3's new fracture would have been documented on his/her care plan. During an interview on [DATE] at 11:13 AM, the Unit Manager stated that she was told by the nurse on [DATE] that Resident #3 had fallen the night before. She stated on [DATE] the X-ray results revealed Resident #3 had a right femur fracture. The Unit Manager stated the femur fracture should have been added to Resident #3's care plan and the care plan should have been updated and revised if needed. She further stated all nurses could update residents' care plans. Interview on [DATE] at 9:00 AM, the MDS Coordinator stated Resident #3's pain and activity of daily living (ADL's) care plan should have been updated and revised when the facility learned of the femur fracture. She stated the fracture should have been discussed in the facility's daily clinical meeting and the resident's care plan revised at that time. In an interview on [DATE] at 9:30 AM, MDS #2 stated she was aware Resident #3 sustained a right femur fracture. She stated certainly, Resident #3's care plan should have been updated and revised when the fracture occurred. She stated she expected the nurse or the Unit Manager who received the X-ray report to update Resident #3's care plan. 2. Review of the closed record for Resident #2 revealed the facility admitted the resident on [DATE], with diagnoses to include: Quadriplegia, Incomplete; Pressure Ulcer of Sacral Region, Stage four (4); Psychotic Disturbance; and Mood and Anxiety Disturbance. Further review revealed Resident #2 was discharged from the facility on [DATE]. Review of the Quarterly MDS Assessment for Resident #2 dated [DATE], revealed the facility assessed the resident to have a BIMS score of fifteen (15) of fifteen (15), indicating he/she was cognitively intact. Review of the Progress Note dated [DATE] at 11:35 AM, signed by the Unit Manager revealed Resident #2 refused to be seen by the wound care NP and refused to have his/her wound vac changed. Continued review revealed Resident #2 said he/she would wait for the night nurse to provide his/her wound care. Review of Resident #2's Comprehensive Care Plan dated [DATE], revealed there was no documented evidence the facility developed the resident's care plan with focus problems related to his/her mood, anxiety, behaviors, or non-compliance and refusal of care. During an interview on [DATE] at 11:13 AM, the Unit Manager stated stated Resident #2 was noncompliant and often refused care. She stated she thought Resident #2 was care planned for those behaviors. In interview on [DATE] at 9:00 AM, the MDS Coordinator stated Resident #2 often made choices that were not right for his/her care. The MDS Coordinator further stated refusal of care as well as non-compliance with care should have been addressed on Resident #2's care plan. In further interview on [DATE] at 9:00 AM, the MDS Coordinator stated the purpose of the care plan was that it drove resident care and allowed staff to know what care a resident needed. She stated the admissions nurse initiated a new resident's baseline care plan and the IDT met to formulate the resident's comprehensive care plan. The MDS Coordinator stated charts were reviewed daily in clinical meeting and they discussed any new orders and falls during those meetings. She stated the nurses on the floor had been trained on care plans and could update and revise the care plans and initiate any new problems for a resident. In an interview on [DATE] at 9:30 AM, MDS #2 stated she had been the MDS Nurse at the facility for five (5) years. She stated care plans were updated by the nurses on the floor. MDS #2 stated the purpose of the care plan was that it drove resident care and allowed staff to know what was required for the resident's care. During an interview on [DATE] at 1:28 PM, the Director of Nursing (DON) stated she had been the DON at the facility for approximately thirty (30) days. She stated her expectation of her staff would be that they updated residents' care plans and revised them as needed when a resident had a change in condition, had orders that affected his/her care, and/or with changes in the resident's ADL's. The DON stated the nurses had been trained on care plans. She further stated she was not employed when Resident #2 and Resident #3's were in the facility and so, she could not speak directly to that. During an interview on [DATE] at 1:45 PM, the Administrator stated she had been Administrator at the facility since [DATE]. She stated her expectation of staff was for residents' care plans to be updated and revised when a resident had a change in condition that required different care. The Administrator further stated the outcome of a resident's care plan not being revised would be that staff would not know what care to provide.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure medical records were accurately documented for one (1) of five (5) sampled residents, Resident #3. On [DATE] Resident #3 was noted with bruising to the right knee and increased pain. An X-ray of the right knee was performed on [DATE] and the results obtained on [DATE] at 5:40 AM, revealed Resident #3 had an acute distal femur fracture with malalignment. However, there was no documented evidence the facility notified the attending Physician until [DATE], nor that Hospice Services was notified. The findings include: Review of the facility policy, Charting and Documentation, revised 07/2017, revealed all services provided to the resident, progress towards the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition was to be documented in the resident's medical record. Review revealed medical records was to facilitate communication between the interdisciplinary team (IDT) regarding the resident's condition and response to care. Continued review revealed the following information was to be documented in the residents' medical records: treatments or services performed; changes in the resident's condition; any events, incidents, or accidents, involving the resident and any treatment services performed. Review further revealed the documentation of procedures and treatments was to include care specific details such as: the assessment data and any unusual findings obtained during the procedure or treatment; and notification of the Physician, family, or other staff, if indicated. Review of the closed medical record for Resident #3 revealed the facility admitted the resident on [DATE], with diagnoses which included: Unilateral Primary Osteoarthritis, Unspecified Knee; Dementia, Unspecified; Osteomyelitis Unspecified and Difficulty in Walking. Review further revealed the resident was admitted to Hospice Care on [DATE], and he/she expired in the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS) Assessment for Resident #3 dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of two (2) indicating he/she was severely cognitively impaired. Review of Resident #3's Progress Note dated [DATE] at 9:52 AM, documented by Licensed Practical Nurse (LPN) #1 revealed the resident complained of pain in his/her right knee, ankle and foot area. Per review, Resident #3's right knee was bruised. Review revealed the Hospice Nurse/Registered Nurse (RN) #4, was at the facility on that date, and questioned Resident #3 about falling. Continued review revealed Resident #3 told Hospice Nurse/RN #4 he/she had not fallen. Further review revealed Hospice Nurse/RN #4 asked if the facility Nurse Practitioner (NP) could assess Resident #3, and she (Hospice Nurse/RN #4) stated she told facility staff she would return later to do the resident's Hospice Recertification. In addition, Hospice Nurse/RN #4 and the facility NP were both aware of Resident #3's bruised right knee area, and pain in the resident's knee, ankle, and foot area and assessed. Review of the Hospice Recertification visit documentation dated [DATE] at 2:05 PM, by Hospice Nurse/RN #4, revealed Resident #3 had complained of increased pain to his/her right knee, ankle, and foot area. Per review, the facility reported Resident #3 had not fallen and that he/she would be unable to get himself/her self up off the floor if he/she had fallen. Continued review revealed Resident #3 had chronic right knee pain; however, stated the pain was unbearable today. Further review revealed Hospice Nurse/RN #4 spoke with the Hospice Supervisor and an order for an X-ray was received. In addition, review further revealed Resident #3 did have chronic history of right knee being swollen due to a recent surgery; however, the swelling was increased. Review of the Progress Note dated [DATE] at 3:16 PM, documented by LPN #1 revealed a new order had been received from Hospice to obtain an X-ray of Resident #3's right knee due to increased pain and swelling with bruising. Review of the X-ray imaging report dated [DATE] at 5:40 AM, revealed the results were fracture of the resident's distal femoral shaft with malalignment; joint space narrowing; and mild soft tissue swelling. Further review revealed the conclusion was noted as an acute appearing femoral fracture. Review of Resident #3's Progress Note dated [DATE] at 8:55 PM; however created on [DATE], by the former Director of Nursing (DON) revealed she spoke with Resident #3's Power of Attorney (POA) regarding the resident's X-ray results which noted a fracture to the right femur. Per review of the Note, the POA agreed that the cause of the fracture was from Resident #3 self-transferring or his/her spouse attempting to transfer the resident. Continued review revealed Resident #3's right leg had a history of issues and of the integrity being compromised due to the multiple infections of the right knee and multiple surgeries. Further review revealed a history of Osteoarthritis, Osteomyelitis, and Osteopenia noted and the POA voiced appreciation for the follow up. In addition, the POA expressed she did not want any surgical intervention for Resident #3, and said the facility should focus on keeping the resident comfortable. Review of the Progress Note for Resident #3 dated [DATE], revealed there was no documented evidence indicating the X-ray results had been received. Continued review revealed no documented evidence the Physician or Hospice had been notified of the results. Review of Resident #3's history and physical, completed by the attending Physician and dated [DATE], revealed the resident had been receiving Hospice care and had a right femur fracture which was pathological, due to long term steroid use. Continued review revealed Resident #3 had painful movement, chronic pain syndrome, vascular Dementia worsening with sundowners; Depression; and Anxiety. Further review revealed Resident #3 had Osteoarthritis of the right knee; previous surgeries; Osteomyelitis of the right tibia; and history of patellar fracture which was non-operable; incontinence of both bowel and bladder; weakened condition, with a poor prognosis. In addition, it was noted Resident #3 had Morphine and Norco, ordered for pain. During an interview on [DATE] at 1:08 PM, the facility's Nurse Practitioner (NP) stated LPN #1 made her aware of Resident #3's bruised knee. She stated Resident #3 started receiving Hospice a few months ago and she did not see the resident other than seeing him/her in the common area. The NP further stated Hospice took care of all Resident #3's needs. She further stated she had not notified the Physician about the resident's bruised right knee, nor of the X-ray results. In an interview on [DATE] at 8:18 PM, LPN #1 stated she made the facility's NP aware of Resident #3's right knee bruising. She stated she did not make the Physician aware; however, she thought the NP had notified the Physician. LPN #1 stated she had not been working when the X-ray results returned to the facility on [DATE]. In an interview on [DATE] at 9:40 AM, Hospice Nurse/RN #4 stated she saw Resident #3 on [DATE], and noted increased pain and bruising to the resident's right knee. She stated Resident #3 had a history of right knee pain. The RN stated she asked LPN #1 if the facility NP could assess Resident #3. She stated the NP ordered an X-ray and she spoke with her Hospice Supervisor and received an order to proceed. Hospice Nurse/RN #4 stated Hospice was not notified of the X-ray results until she visited Resident #3 on [DATE]. In an interview on [DATE] at 11:28 AM, the Physician stated he had been notified of Resident #3's right femur fracture when the X-ray results were received. He stated the former DON, or the floor nurse made him aware. The Physician stated Resident #3 had multiple issues with his/her right knee and received steroids. He further stated Resident #3's femur fracture was a pathological fracture. During an interview on [DATE] at 5:33 PM, the former Director of Nursing (DON) stated she could not recall reporting Resident #3's X-ray results to the attending Physician. She stated she did recall calling the POA and it was decided at that time that no surgical intervention would be done. In continued interview the former DON, stated she could not speak to Resident #3's injury and an injury of unknown origin as the Physician stated it was a pathological fracture. The former DON stated she could not recall if that was documented prior to [DATE] or not. During an interview on [DATE] at 1:45 PM, the Administrator stated she had been a Licensed Nursing Home Administrator for a year, and had been at the facility since [DATE]. She stated she expected all staff to follow policies and procedures of the facility. The Administrator stated she expected the nurses to notify the Physician when a change in condition occurred to a resident, and to document the notification in the medical record as per the policy.

Based on observations, interviews, and review of the facility's policy, it was determined the facility failed to ensure one (1) of fourteen (14) sampled residents (Resident #3) was free from misappropriation of narcotic medications. During a narcotic count, at change of shift, on 11/09/2022, it was determined Resident #3 was missing fifteen (15) tablets of seven and one-half (7.5) milligram (mg) Oxycodone/APAP (Acetaminophen), a narcotic pain relief medication. The findings include: Review of the facility's policy, Abuse, Neglect and Exploitation, dated 01/02/2022, and revised 08/30/2022, revealed the facility would provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibited and prevented abuse, neglect, exploitation and misappropriation of resident property. Continued review revealed the definition of misappropriation of resident property meant the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. Employees would be educated on abuse, including misappropriation of residents' property during initial orientation, and annual education through planned in-services and, as needed. Review of the Pharmacy Services' policy,Discrepancies, Loss and/or Diversion of Medications, revised 01/2018, revealed all discrepancies, suspected loss and/or diversion of medications, irrespective of drug type or class, would be immediately investigated and a report filed. Further review of the policy revealed immediately upon the discovery or suspicion of a discrepancy, suspected loss or diversion, the Administrator, Director of Nursing (DON) and Consultant Pharmacist would be notified, and an investigation conducted, with the DON leading the investigation. Record review revealed during the process, the Consultant Pharmacist would verify suspected loss. Continued review revealed the DON would investigate the discrepancy and research all the records related to medication administration and the supply of the medication, including medication reconciliation. Medication reconciliations were made from the last known date and time of the reconciliation (e.g., during the last shift count, receipt of a full medication container). Additional review revealed the DON investigated suspected loss and researched all the records related to medication receipt; its use since receipt; all persons involved with medication administration; the supply of the medication; and, identified the last known point in time that the medication was available. The dispensing pharmacy should be notified, and the pharmacy should verify that the medication was actually dispensed. Record review revealed the facility admitted Resident #3, on 08/23/2020, with diagnoses which included Type 2 Diabetes Mellitus without complications, Aphasia following cerebral infarction, Unspecified mood (affective) disorder, and Anxiety Disorder. Further review of the record revealed Resident #3's Physician's Orders included Oxycodone/APAP 7.5 mg-325 mg by mouth every six (6) hours, as needed for pain. Review of the Long-Term Care Facility Self-Reported Incident Form, dated 11/09/2022, revealed the facility self-reported exploitation/misappropriation of property. Further review revealed notifications were made to the Physician, Local Law Enforcement, Appropriate Licensing Board, and the Ombudsman. Review of the Five (5) Day Report, dated 11/15/2022, revealed after the narcotics were reported missing, the DON was notified, who advised an investigation would begin and no nurse could leave the building. Further review revealed the nurse on duty was questioned, as well as the oncoming nurse, for the same medication cart and another nurse witness. Continued review revealed the nurse's statement that she had pulled the wrong card with the DON and Assistant Director of Nursing (ADON) noting an empty card of Oxycodone/APAP 7.5-325 mg should have had 15 tablets and the identifier label had been removed. Additional review of the Self-Reported Incident Form, revealed the nurse (Registered Nurse #5) acknowledged she had removed all the tablets from the card and planned to place them in a pill bottle and fix the count sheet. The nurse had signed out two (2) tablets to Resident #3, three (3) times during her shift. Further review revealed twelve (12) of the tablets were recovered and were submitted to the DON, while three (3) tablets were missing. Review of the Five (5) Day Report revealed the nurse admitted to taking the medication with intent to ingest the pills later. The nurse stated while alone in the conference room, she had disposed of the three (3) missing tablets in the sink. Further review revealed the nurse's employment had been terminated. Review of Resident #3's Electronic Medical Record (EMR), revealed periodic use of as needed pain medication was ordered for the resident. Review of the resident's Oxycodone/APAP sign out sheet revealed Registered Nurse (RN) #5's signature documenting she had removed two (2) tablets and signed three (3) different times during day shift on 11/09/2022. Review of RN #5's personnel file, on 01/03/2023 at 11:47 AM, revealed a history of prior license restrictions from the Kentucky Board of Nursing (KBN) related to substance abuse. Additional review revealed her restrictions were lifted on 05/18/2022 and her RN license was unencumbered. Further review revealed her employment was terminated on 11/10/2023. Observation, of a narcotics count, on 01/04/2023 at 3:06 PM, with Licensed Practical Nurse (LPN) #1 and the Assistant Director of Nursing (ADON), revealed accurate counts of all controlled medications, cards and documentation. There were no discrepancies and no breaches of policy or practice. Interview, with Licensed Practical Nurse #2, on 01/05/2023 at 10:18 PM, revealed she had worked the night of 11/08/2022. LPN #2 stated she returned the following night, so she was aware of the medications for Resident #3 that were in the cart when she departed that morning. Further interview revealed she asked RN #5 where the Oxycodone/APAP card was and that she had replied, I don't know what you are talking about. LPN #2 stated she reported the discrepancy to the DON right away. Continued interview revealed RN #5 went to the medication room, and had pulled the card from somewhere, then begged LPN #2 not to talk. LPN #2 stated that RN #5 stated, We can fix this, we can put them in a pill bottle and make up a shift count. Additional interview revealed RN #5 had also stated she had wasted all the pills with RN #2. LPN #2 stated she did not believe this and walked away to find RN #2, who stated she had not wasted any pills. Interview, with LPN #1, on 01/04/2023 at 3:33 PM, revealed the process for resolving a narcotic discrepancy included: the two (2) nurses, the off going and oncoming staff worked together to find errors; back trace their steps, and look up medications given compared to those signed out on the individual narcotic documentation sheets. Further interview revealed they would call the DON and go from there with her instructions. Continued interview revealed the expectation was the nurses would sign the narcotic documentation sheet as medications were given, and chart it in Matrix at that time. Interview, with Registered Nurse (RN) #2, on 01/05/2023 at 11:59 AM, revealed she did not know anything was going on until the shift count. She stated she was on another cart. Further interview revealed the oncoming nurse counting the meds dropped the lid and said I'm not taking the cart and that's when everything broke loose. RN #2 stated the oncoming nurse didn't want to accept the cart. She stated RN #5 talked to her, stating I'm in trouble, I'm missing some narcotics. RN #2 stated she replied that the nurses would all just get drug tested, to which RN #5 replied she would test positive. Continued interview revealed she knew RN #5 had an injury to her foot, a stress fracture, so she thought she had a prescription for pain medication and had remarked that even if RN #5 tested positive, she had a prescription. Additional interview revealed RN #5 looked at her and stated, I'm going to lose everything. RN #2 stated she could not leave until the DON arrived and resolved the discrepancy, then RN #5 came back out with the narcotic documentation sheet with signatures already on it, and told her she was going to say RN #2 signed off with her, to which she replied that she had not signed off any medication and would not say she signed any meds off. RN #2 stated she gave her witness statement and was then allowed to leave. Review of the Police Department (PPD) report, dated 11/10/2022, revealed they had received the report on 11/10/2022 at 12:04 AM, and arrived at the facility at 12:09 PM. Further review revealed the PPD arrested RN #5 and charged her with Theft by Unlawful Taking. Continued review of the arrest citation revealed RN #5 admitted to the officer she had taken the medication from the cart only she had access to. Additional review revealed that RN #5 stated she had flushed three (3) pills down the sink. Interview, with the Assistant Director of Nursing (ADON), on 01/06/2023 at 10:43 AM, revealed they did know RN #5 had an encumbered license at the time of hire. She stated they learned the limitations for her and followed KBN's restrictions. The ADON stated the DON worked with RN #5 and was sure she had documentation on restrictions, then was released from KBN. She also stated RN #5 had an unencumbered license shortly after hire until her termination. The ADON stated all nurses had received abuse training which included information that misappropriation was a form of abuse and RN #5 had this training upon hire. Interview, with the Director of Nursing (DON), on 01/06/2023 11:59 AM, revealed her recollection that RN #5 was not hired until June, after her restrictions were lifted, and was aware of her having been in the Kentucky Alternative Recovery Effort (KARE) program. She also stated RN #5 had abuse training which included misappropriation at hire. The DON stated on the date of the incident, the night shift nurse called and stated there was a narcotic card missing, to which she gave instructions that no nurse could leave the building. She stated RN #5 was not to let go of the keys. The DON stated she contacted the ADON and Administrator. Continued interview revealed she initiated an investigation, while RN #5 had been moved to the conference room to write a statement and wait while she and the ADON counted the medications on all carts and interviewed the day shift nurse. Additional interview revealed when RN #5 was with the ADON, she stated she accidentally took the top of the card off while removing the top of another card that was to be discarded. The DON stated RN #5 said she tried to fix it by putting the tablets in a bottle. Subsequent interview revealed she asked RN #5 why she did not report it right away so it could have been addressed at the time it happened. The DON stated RN #5 said she discarded three (3) pills down the sink. She stated the nurse had made statements of suicidal ideation and was released to her mother, who transported her to a local hospital where she was later arrested. Interview, with the Administrator, on 01/06/2023 at 1:05 PM, revealed she was not the administrator at the time RN #5 was hired. Continued interview revealed she was notified of the narcotic count being off, so she and the DON both came to the facility. The Administrator stated RN #5 stated she popped 15 pills from the card and had kept three (3) to ingest at a later time. Interview revealed the other twelve (12) pills were accounted for. The Administrator stated RN #5 stated that she had flushed the three (3) pills down the sink while in conference room to write her statement. Additionally, the Administrator stated RN #5 made statements of intent for self harm, and she departed with her mother transporting her to the hospital. She stated the police arrived after RN #5's departure, who notified them later that she had, in fact, gone to the hospital, where she was arrested. The Administrator stated the narcotic sheet appeared as though she had attempted to make it reflect administrations to the resident; and she had signed another nurse's name as though they had wasted the pills. The Administrator stated the other nurse stated it was not her signature, and she had not wasted any pills with RN #5. Continued interview revealed the ADON interviewed the resident, who stated he/she had not taken any pain medicine that day.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure that an alleged violation of sexual abuse was reported immediately, to the State Survey Agency, but not later than two (2) hours after the allegation was made for one (1) of five (5) residents reviewed for abuse of fourteen (14) sampled residents. (Resident #1). Record review revealed, on 11/27/2022, Resident #1 reported to Certified Nursing Assistant (CNA) #10, that he/she had been sexually assaulted. Further review of the record revealed no documented evidence the facility reported the allegation to the State Survey Agency (SSA). The findings include: Review of the facility's policy, Abuse, Neglect and Exploitation, revised 08/30/2022, revealed it was the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibited and prevented abuse, neglect exploitation and misappropriation of resident property. Continued review revealed, reporting of all alleged violations to the Administrator, the State Agency, Adult Protective Services (APS) and to all other required agencies within specified timeframes. Immediately, but not later than two (2) hours, after the allegation was made in the event the allegation involved abuse. Closed record review revealed the facility admitted , Resident #1 on 09/22/2020, with diagnoses which included Multiple Sclerosis, Bipolar Disorder and Obesity. Review of Resident #1's Discharge Minimum Data Set (MDS) Assessment, dated 12/15/2022, revealed a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen, which indicated Resident #1 was cognitively intact. Review of section G, Functional Status, revealed, Resident #1 was not ambulatory (could not walk) and required the use a mechanical lift for all transfers. Review of the text message witness statement, dated 11/27/2022, which was provided via text message to the State Survey Agency, and signed by Certified Nursing Assistant (CNA) #10, revealed around 5:00 PM, she answered Resident #1's call light and he/she complained that his/her catheter was leaking and she informed the nurse. About twenty minutes later, at 5:20 PM, while passing dinner trays, CNA #10 entered Resident #1's room and noted a water cup on the floor. She asked Resident #1 and his/her roommate what happened and Resident #1 stated, It was me, I've been raped. She asked again what had happened and Resident #1 stated, I've been raped, about four or five minutes ago. CNA #10 immediately reported to Registered Nurse (RN) #3. Interview, with Certified Nursing Assistant (CNA) #10, on 01/05/2023 at 2:55 PM, revealed that on 11/27/2022 at approximately 5:20 PM, she answered Resident #1's call light. She stated Resident #1 looked upset and she could not tell if he/she was joking around or not as he/she sometimes did. The CNA stated she asked Resident #1 what was wrong, and he/she said someone had came in his/her room and raped him/her. She stated she asked Resident #1 exactly what happened and he/she stated he/she was raped. CNA #10 stated she informed Registered Nurse (RN) #3 immediately and she and Licensed Practical Nurse (LPN) #5 went to Resident #1's room. Additional interview with CNA #10, revealed she had completed a statement about Resident #1's allegations of sexual abuse and had provided it to the facility. Review of the facility's witness statement, dated 11/27/2022, and signed by RN #3, revealed CNA #10 had informed her that Resident #1 was visibly upset, crying, and had stated someone sexually assaulted him/her. RN #3 and Licensed Practical Nurse (LPN) #5 went into Resident #1's room and the resident reported to them that a man had come into his/her room, got him/her out of bed, held him/her against the wall in the corner and fucked me in my ass for 30 minutes and I couldn't get him to stop. RN #3 immediately reported to the Director of Nursing (DON) and Resident #1's responsible party. Interview, with Licensed Practical Nurse (LPN) #5, on 01/04/2023 at 8:18 PM, revealed that on 11/27/2022, she was working at the facility on the 300 Hall. She stated RN #3 had asked her to come to Resident #1's room. The LPN stated Resident #1 was upset and crying. She stated RN #3 asked the resident what had happened and he/she said they had tried to get the man off (him/her) but could not. LPN #5 stated Resident #1 said someone came in the room and pushed him/her in the corner and, fucked me in the ass for thirty minutes and then ran out of the room. Additionally, LPN #5 further stated Resident #1 was being treated for a urinary tract infection and had altered mental status. She stated Resident #1 was not able to walk and used a mechanical lift for transfers. Interview, with Registered Nurse (RN) #3, on 01/05/2023 at 5:42 PM, revealed on 11/27/2022, CNA #10 reported to her that Resident #1 had voiced to her that he/she had been raped. RN #3 stated she asked LPN #5 to go to Resident #1's room with her and Resident #1 told them that someone had held him/her against the wall and raped him/her. RN #3 stated she notified the Director of Nursing (DON) and completed an assessment including an assessment of the anal area. She further revealed she did not notice anything abnormal and that Resident #1 was wearing a brief. Review of a Progress Note, dated 11/28/2022 at 7:30 AM, and signed by the DON, revealed Resident reviewed by Interdisciplinary Team (IDT) due to reports of sexual assault as per nursing documentation. Upon further investigation with resident, he/she stated that when he/she alleged this happened he/she threw peaches and coke at them but couldn't identify any staff as being the ones that did the assault. There was no evidence the resident had thrown peaches or coke on the floor. Resident was also unable to get out of bed and was of significant weight and required a mechanical lift for transfers. Further review revealed Resident #1 had received care throughout the night per usual. Resident #1 was noted with behaviors of making statements like this at times. Staff would ensure to attend to his/her needs with at least two (2) staff members present during routine care and report any concerns/complaints to nurse. This nurse and administrator met with resident's sister regarding investigation and sister expressed noted confusion with resident. Resident currently being treated for UTI and having increased periods of confusion. Interview, with the Director of Nursing (DON), on 01/06/2023 at 12:29 PM, revealed that on 11/27/2022, RN #3 notified her that Resident #1 had stated a man had come into the room, held him/her in the corner and sexually assaulted the resident. The DON stated she asked questions and had RN #3 assess Resident #1. The DON stated she notified the Administrator and initiated the investigation. She stated the incident was not reported to the required entities, State Agency, Adult Protective Services (APS). Further, the DON stated that she could not speak to the facility's policy without looking at it. She stated that she or the Administrator would be responsible for reporting the allegation. The DON stated she was not going to say the facility failed to follow its policy and going forward she would expect allegations of abuse to be reported to the appropriate entities. Interview, with the Administrator, on 01/06/2023 at 1:54 PM, revealed on 11/27/2022, the DON informed her that Resident #1 had alleged someone had gotten him/her out of bed, pushed him/her against the wall and sexually assaulted him/her. She stated the allegation was not reported to the required entities, State Agency, Adult Protective Services (APS) or to law enforcement. She further stated, looking back at it now, the facility should have reported the allegation to the required entities. The Administrator stated she or the DON would be responsible for investigating and reporting allegations of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews it was determined the facility failed to provide privacy covers for a urinary catheter drainage bag for two (2) of three (3) residents sampled for catheters (Resident #67 and Resident #79). The findings included: 1. Record review revealed Resident #67 was admitted to the facility 07/08/2021 with a diagnosis of acute kidney failure with tubular necrosis. Review of the Significant Change Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #67's Brief Interview for Mental Status (BIMS) score to be fifteen (15), which indicated the resident was cognitively intact. Further review of the MDS revealed Resident #67 had an indwelling catheter. Review of Resident #67's care plan, dated 07/08/2021, revealed the resident had a focus of having a catheter, with measurable goals and interventions. Observation on 08/30/2021 at 3:28 PM, revealed Resident #67 was in a reclining chair with his/her catheter hooked to the nightstand next to the chair. Further observation of the catheter bag revealed clear, yellow urine, and was absent of a catheter bag privacy cover. Observation on 08/31/2021 at 2:09 PM, revealed Resident #67's catheter bag contained yellow, clear urine and no privacy cover over the catheter bag. Interview with Resident #67, on 08/31/2021 at 2:09 PM, revealed he/she had never seen a cover over the catheter bag. Interview with Licensed Practical Nurse (LPN) #9, on 08/31/2021 at 3:13 PM, revealed they were going to put a cover over the catheter bag, but they got sidetracked. LPN #9 further revealed every resident should have a privacy cover on their catheter bags but could not state why Resident #67's did not have one. Interview with the Director of Nursing (DON), on 09/01/2021 at 2:35 PM, revealed all urinary catheter bags should have a privacy cover to respect the dignity of the resident. The DON stated they did not know why there was not one in place. Interview with the Nursing Home Administrator (NHA), on 09/01/2021 at 2:35 PM, revealed that their expectation was for all catheters to be covered for privacy. 2. Record review revealed the facility admitted Resident #79 on 08/10/2021 with a diagnosis of malignant neoplasm of prostate. Review of the admission Minimum Data Set (MDS), dated [DATE], revealed Resident #79's Brief Interview for Mental Status (BIMS) score was 10, which indicated the resident was moderately cognitively impaired. Further review of the MDS revealed the resident had an indwelling catheter. Review of Resident #79's care plan, dated 08/11/2021, revealed a focus of having a catheter, with measurable goals and interventions. Observation on 08/30/2021 at 8:37 AM, revealed Resident #79 lying in bed and his/her catheter bag was hanging on the side of the bed and was visible from the door. Further observation revealed the bag was half full of dark yellow urine, and no privacy cover in place over the bag. Observation on 08/30/2021 at 3:46 PM, revealed Resident #79 in a wheelchair in the common area, with no privacy cover over his/her catheter bag. Resident #79 was not interviewable. During an interview with Nursing Assistant (NA) #54, on 08/31/2021 at 4:00 PM, revealed she did not know why the drainage bag was not covered. The NA stated the nurse was responsible for the urinary catheter bags. Interview with LPN #9, on 08/31/2021 at 3:13 PM, revealed the resident's urinary catheter bag should have had a privacy cover. Interview with the DON, on 09/01/2021 at 2:35 PM, revealed all urinary catheter bags should have a privacy cover to respect the dignity of the resident. The DON did not know why there was not one in place. Interview with the NHA, on 09/01/2021 at 2:35 PM, revealed their expectation was for all catheters to be covered for privacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and facility policy review, it was determined that the facility failed to ensure two (2) of three (3) sampled residents (Resident #32 and Resident #39) whose clinical records were reviewed for advanced directives had been provided information about advance directives and/or were offered assistance to formulate an advance directive, if desired. This had the potential to affect eighty-three (83) residents residing in the facility. The findings included: Review of the facility's policy, titled, Residents' Rights Regarding Treatment and Advance Directives, implemented 03/22/2021, revealed, It was the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. On admission, the facility would determine if the resident had executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive. The facility would provide the resident or resident representative information, in a manner that was easy to understand, about the right to refuse medical or surgical treatment and formulate an advance directive. During the care planning process, the facility would identify, clarify, and review with the resident or legal representative whether they desired to make any changes related to any advance directives.Decisions regarding advance directives and treatment would be periodically reviewed as part of the comprehensive care planning process, the existing care instructions and whether the resident wished to change or continue these instructions. 1. Record review revealed the facility admitted Resident #32 on 02/21/2019 with diagnoses which included paraplegia and Stage 3 chronic kidney disease. The Medicare 5-day Minimum Data Set (MDS), dated [DATE], indicated the resident was independent with cognitive skills for daily decision making. Further record review revealed the resident was his/her own responsible party and there was no documented evidence the resident had been provided information regarding advance directives and/or was offered assistance to formulate an advance directive. Interview with the Director of Nursing (DON), on 09/01/2021 at 1:41 PM, revealed after reviewing the resident's clinical record there was no documentation which indicated the resident had been provided information about advance directives and/or had been offered assistance to formulate an advance directive. 2. Record review revealed the facility admitted Resident #39 on with diagnoses which included acute kidney failure and major depressive disorder. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident's Brief Interview for Mental Status (BIMS) score was 15, which indicated the resident was cognitively intact. Further record review revealed the resident was his/her own responsible part. Record review revealed there was no documented evidence the resident had been provided information regarding advance directives and/or was offered assistance to formulate an advance directive. Interview with the DON, on 09/01/2021 at 1:40 PM, revealed after reviewing the resident's clinical record there was no documentation which indicated the resident had been provided information about advance directives and/or had been offered assistance to formulate an advance directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and facility policy review, it was determined the facility failed to ensure one (1) of thirty-eight (38) sampled residents (Resident #7) received an accurate assessment to reflect the resident at the time of the assessment. Specifically, the facility failed to accurately assess Resident #7's dental status. The findings included: Review of the Resident Assessment Instrument (RAI) Version 3.0 Manual on Coding Instructions, for section L0200, Oral/Dental Status, revealed that L0200B should be marked if the resident lacks all or parts of teeth, and L0200D should be marked if any cavity or broken tooth was seen. Record review revealed the facility admitted Resident #7 on 05/24/2021 with diagnoses which included atherosclerotic heart disease, type 2 diabetes, and hypertension. The admission Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was ten (10), which indicated moderate cognitive impairment. According to the MDS, there were no issues with the resident's teeth. Review of the admission Nursing Bundle, revealed Resident #7 did not have any issues with their teeth. The Dental/Nutrition section was marked none of the above. Interview with Resident #7, on 08/30/2021 at 12:21 PM, revealed he/she did not have any teeth on the top, and he/she was missing some teeth on the bottom. The resident showed this Surveyor their mouth during this interview to confirm missing teeth. Interview with the Assistant Director of Nurses (ADON), on 09/02/2021 at 8:53 AM, revealed that everyone was screened upon admission using the admission Bundle, which was a detailed form in the resident's clinical record to record health status which included dental questions. She verified that the assessment stated none was marked under the Dental/Nutrition section, indicating there were no issues with Resident #7's teeth. The ADON went to see Resident #7 and asked if she could examine the resident's mouth and teeth. The resident agreed, and she put on gloves and looked at the resident's mouth and teeth. The resident told her there was no pain, but there had been difficulty chewing. The ADON stated that there were several missing teeth and a couple teeth were broken. She stated the resident needed a dental consult, and it appeared that the assessment and MDS were inaccurate for the condition of the resident's teeth. Interview with Licensed Practical Nurse (LPN) #41, on 09/02/2021 at 9:16 AM, revealed she was working on the next Quarterly MDS. She further revealed Resident #7 had stated they were having trouble chewing meats, and she notified the Dietary Manager (DM) to get the resident's diet changed to mechanical soft. The resident was then able to eat the ground meat easier. LPN #41 further stated if the assessment had been documented correctly, Resident #7 would have been referred to the dentist. Interview with the Social Worker, on 09/02/2021 at 9:38 AM, indicated the dentist came approximately every four (4) months, but residents could also be sent out for dental care if needed. The Social Worker further stated the goal was to have every resident seen by a dentist at least yearly. She stated she was not aware Resident #7 had missing and broken teeth. Interview with Speech Therapist #99, on 09/02/2021 at 9:47 AM, revealed that Resident #7 was on the regular caseload and received a mechanical soft diet. The Speech Therapist stated Resident #7 always denied having oral pain. Further interview revealed she had not looked at the resident's mouth after the resident was added to the therapy caseload. Interview with LPN #7, on 09/02/2021 at 10:34 AM, revealed that Resident #7 chose to receive a mechanical soft diet and had never mentioned teeth problems to her. Interview with the Director of Nursing (DON), on 09/02/2021 at 10:09 AM, indicated that it would be poor dentition if a resident had missing or broken teeth and she had never heard that this resident could not chew meats. She further stated she was unsure what the nurse who did the assessment was thinking when she marked Resident #7 as none for dental issues. The DON stated the MDS was pulled from the nurse's assessment.

Based on interviews, record reviews and facility policy review, it was determined the facility failed to include the diagnoses of anxiety disorder and bipolar disorder on the pre-admission screening and the resident review (PASRR) Level I. Further review revealed the facility failed to complete a Level II PASRR screening to include new mental health diagnoses of major depressive disorder and Schizophrenia for one (1) of two (2) residents sampled for PASRR level II (Resident #47). The findings included: Record review revealed the facility admitted Resident #47 on 08/05/2020 with diagnoses including anxiety disorder and bipolar disorder. Review of the diagnoses listed in the medical record, Resident #47 was diagnosed with major depressive disorder on 08/26/2020 and schizophrenia on 11/15/2020. Review of the 5-day Minimum Data Set (MDS) assessment, dated 07/29/2021, revealed the resident's Brief Interview for Mental Status (BIMS) score was fifteen (15), which indicated the resident was cognitively intact. Further review of the MDS revealed Resident #47 had diagnoses of anxiety, bipolar disorder, depression, and schizophrenia and received an antipsychotic and an antidepressant. Review of Resident #47's care plan, dated 07/29/2021, revealed the resident was at risk for changes in mood state and psychosocial well-being. The resident had a mood problem related to (r/t) anxiety and bipolar. Further review of the care plan revealed Resident #47 used antidepressant medication r/t depression and used psychotropic medications r/t diagnosis of bipolar. Review of the PASRR, dated 08/05/2020, read in pertinent part, Section 2: Mental Illness Diagnosis: Identify whether the individual has a current diagnosis for or is suspected to have a diagnosis of a major mental illness (such as psychotic disorder, mood, paranoid, panic or other severe anxiety disorder, or Post Traumatic Stress Disorder). If none identified, check No in Box 2d. Review of Resident #47's PASRR, revealed the name of condition area was left blank, and it was checked No. Interview with Admissions Director (AD) #70, on 09/01/2021 at 11:19 AM, revealed they had been in the facility since June 2021 but was not in the facility when this screening for Resident #47's PASRR was completed. The employee also stated when a screening was completed for a resident, it should include all mental health diagnoses. The AD stated there were no diagnoses of bipolar disorder or anxiety disorder on the completed 08/05/2020 PASRR Level I Screen and both diagnoses were active on the date of 08/05/2020. The AD further stated the new diagnoses of major depressive disorder, added on 08/26/2020, and schizoaffective disorder, added on 11/15/2020, should have been cause for a PASRR Level II screening which was not completed. Interview with the Director of Nursing (DON), on 09/01/2021 at 2:35 PM, revealed when there was a screen for PASRR Level I, all diagnoses were expected to be included in the screening to ensure the resident was appropriate for the level of care provided by the facility. The DON further stated when there were new mental health diagnoses, there should be a screening for a PASRR Level II. Interview with the Nursing Home Administrator (NHA), on 09/01/2021 at 2:35 PM, stated a PASRR Level I and a PASRR Level II were expected to be completed as needed for all residents.

Based on observations, interviews, record reviews, and review of the facility's policy, it was determined the facility failed to ensure a comprehensive care plan was developed for one (1) of twenty-five (25) sampled residents reviewed for care plans (Resident #2). Specifically, the facility failed to have a care plan for the use and care of Resident #2's urinary catheter. The findings included: Review of the facility's policy, Care Plans, Comprehensive Person-Centered, revised December 2016, revealed the interdisciplinary team (IDT), in conjunction with the resident and family or legal representative, should develop and implement a comprehensive, person-centered care plan for each resident through analysis of the information gathered as part of the comprehensive assessment. Record review revealed the facility admitted Resident #2 on 09/22/2020 with diagnoses which included cerebral infarction (stroke) with neuromuscular dysfunction of the bladder. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 05/18/2021, revealed the facility assessed Resident #2's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) out of fifteen (15), which indicated the resident's cognition was severely impaired Further review of the MDS revealed the resident had an indwelling catheter in the bladder. Review of Resident #2's comprehensive care plan, initiated 09/22/2020, revealed the facility had not initiated a care plan for the use and care of the resident's urinary catheter until 08/31/2021, during the survey. Further review of the care plan revealed no care plan directives for the care of the catheter under activities of daily living (ADLs). Observations on 08/30/2021 at 11:41 AM revealed Resident #2 was lying in bed and a catheter drainage bag with light yellow urine was hanging on the side of the bed facing away from the door. Record review revealed Resident #2 had Physician's Orders for an indwelling catheter for neurogenic bladder. Further review of the Physician's Orders noted the size of the catheter, how often to change the drainage bag and tubing, catheter care, and irrigation orders. Interview with Licensed Practical Nurse (LPN) #7, on 09/01/2021 at 2:24 PM, revealed any resident with a catheter should have a care plan that included the care of the catheter. She further stated it was the administrative nurse's responsibility to initiate the care plan, but any of the floor nurses could update the care plan. Interview with LPN #88, 09/01/2021 at 2:45 PM, revealed any resident with a catheter should have a care plan that included the reason for the catheter and the care of the catheter. Interview with MDS Registered Nurse (RN) #4, on 09/02/2021 at 10:00 AM, revealed areas that needed to be care planned were identified based on the comprehensive assessment, diagnoses, medications, and resident wants and needs. She further stated any resident with a urinary catheter should have a care plan that included the reason for the catheter, the type of catheter including the size of the tubing and the balloon, and the care of the catheter. MDS RN #4 further stated Resident #2's catheter had been captured on the MDS, however, she could not give a reason why the resident did not have a care plan prior to the survey. Interview with the Director of Nursing (DON), on 09/02/2021 at 10:30 AM, revealed residents with catheters should have a care plan that included the reason for the catheter, the size of the catheter, and the care of the catheter. She further stated the MDS Coordinators were responsible for initiating the care plan based on the MDS assessment, but any of the nursing staff could update the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and review of the facility's policy, it was determined the facility failed to review and revise the care plan after a fall for one (1) of two (2) sampled residents reviewed for falls (Resident #50). Specifically, the facility failed to update Resident #50's care plan with new interventions after falls. The findings include: Review of the facility's policy, titled, Falls Management Program Guidelines, undated, revealed the resident's care plan should be updated to reflect any new or change in interventions. Record review revealed the facility admitted Resident #50 on 07/20/2021 and readmitted the resident on 08/12/2021, with diagnoses which included altered mental status, congestive heart failure, epilepsy (seizures), unsteady gait, repeated falls, and wedge compression fracture of the first lumbar vertebra. Review of the admission Minimum Data Set (MDS), dated [DATE], revealed Resident #50's cognition was moderately impaired, with a Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15). Further review revealed the resident had one fall with no injury prior to admission. Review of a Nurse's Progress Note, dated 07/21/2021, revealed Resident #50 was found on the floor in the resident's room. The 07/21/2021 Post-Fall Review revealed the resident was trying to go to the bathroom and stubbed a toe causing the resident to fall. Further review of the Post-Fall Review revealed an immediate intervention was initiated to educate staff to keep the path to the restroom clear of clutter. It also indicated that physical and occupation therapy referrals were made. Review of Resident #50's comprehensive care plan, dated 7/20/2021, revealed it was not updated to include the new interventions. Review of the Nurse's Progress Notes, dated 08/21/2021, revealed Resident #50 was found sitting on the floor on the right side of the bed on the landing mat. The resident stated they were going to turn off the hall lights. The 08/21/2021 Post-Fall Review revealed the cause of the fall was due to the room and hall being too bright for the resident to sleep comfortably. Further review of the Post-Fall Review revealed an immediate intervention was to place the resident on 15-minute checks and educate the staff to ensure the room and hall lights were dimmed for the resident to sleep comfortably. Further review of the record revealed the 15-minute checks occurred for three (3) days and then were discontinued. Review of the fall-risk care plan revealed it had been updated with the 15-minute checks but did not include ensuring the hall and resident's room lights were dimmed. The 15-minute checks were not removed from the resident's care plan when they were discontinued. Observation on 08/30/2021 at 10:36 AM, revealed Resident #50 was observed in their room, lying in bed with the head of the bed elevated 45 degrees. The resident's bed was in a low position with a gray fall mat on the right side of the bed. The path to the bathroom was clear. The lights were dimmed. Interview with Licensed Practical Nurse (LPN) #7, on 09/01/2021 at 2:24 PM, revealed when a resident fell, an intervention was initiated immediately, and the care plan should be updated with that intervention by the nurse on the floor. Interview with LPN #88, on 09/01/2021 at 2:45 PM, revealed when a resident fell, the nursing administrative staff discussed the fall with the nurse to come up with new interventions. She further stated the nurse on the floor should update the care plan and then when the Post-Fall Review was done with the interdisciplinary team (IDT), they would update the care plan if needed. Interview with the MDS Registered Nurse (RN), on 09/02/2021 at 10:00 AM, revealed nursing should update the care plan immediately with any new interventions after a fall, and then when it was reviewed with the IDT, necessary changes would be made at that time. Interview with the Director of Nursing (DON), on 09/02/2021 at 10:30 AM, revealed when a resident fell, interventions were put into place by the nurse on duty with the assistance of the DON or Assistant Director of Nursing (ADON). She further stated the care plan was updated by the nurse and then reviewed by the IDT and updated if needed. The DON stated Resident #50's care plan should have been updated on 07/21/2021 to include the interventions of keeping the pathway to the bathroom clear and for the physical and occupational therapy referrals that were made. She said the intervention put into place after the 08/21/2021 fall, dimming the room, should have been added to Resident #50's care plan.

Based on interviews, record reviews, and facility policy reviews, it was determined that the facility failed to provide care and services according to professional standards of practice for one (1) of two (2) sampled residents reviewed for falls (Resident #50). Specifically, the facility failed to ensure nursing completed neurological (neuro) checks after Resident #50 had an unwitnessed fall on 07/21/2021 and failed to ensure nursing obtained new vital signs with each neurological check completed for Resident #50 after a fall on 08/04/2021. The findings included: Interview with the Director of Nursing (DON), on 09/02/2021 at 10:30 AM, revealed the facility did not have a policy specific to neurological checks. Record review revealed the facility admitted Resident #50 on 07/20/2021 and readmitted him/her on 08/12/2021, with diagnoses which included altered mental status, congestive heart failure, epilepsy (seizures), unsteady gait, repeated falls, and wedge compression fracture of the first lumbar vertebra. Review of the admission Minimum Data Set (MDS) assessment, dated 07/27/2021, revealed Resident #50 was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15). Further review of the MDS revealed the resident had one fall with no injury prior to admission to the facility. Review of Nurse's Progress Notes, dated 07/21/2021, revealed Resident #50 was found on the floor in the resident's room at 2:20 PM and indicated neuro checks were started. According to the neurological observation tool, vital signs, including temperature, pulse, respiration, and blood pressure should be checked, along with the resident's level of consciousness, orientation, pupil size and reaction, responses to simple commands, movement and strength of extremities, speech, and pain. The Post-Fall Review revealed the fall was unwitnessed. Review of the neuro checks form completed for this fall revealed it was only documented as being done once at 2:40 PM. Review of Nurse's Progress Notes, dated 08/04/2021, revealed Resident #50 was found lying on the floor on the left side of the bed. The Post-Fall Review indicated the fall was unwitnessed. Review of the neuro checks done for this fall revealed neuro checks were done but the same set of vital signs taken at the time of the fall at 11:35 PM were used again on 08/05/2021 at 12:35 AM, 12:50 AM, 1:05 AM, 4:35 AM and 5:05 AM. Review of the Nurse's Progress Notes, dated 08/13/2021, revealed the resident was found crawling on the floor in the front lobby, and neuro checks were within normal limits. The Post-Fall Review revealed the fall was unwitnessed. Review of the neuro checks completed from 08/13/2021 at 10:30 PM until 08/14/2021 at 1:30 AM, revealed the same vital signs were used for each neuro check instead of a new set of vital signs being completed. The vital signs documented on these checks were obtained on 08/14/2021 at 1:21 AM. Review of the Nurse's Progress Notes, dated 08/17/2021, revealed the resident was found lying on the right side of the bed on the floor, and neuro checks were intact. The Post-Fall Review revealed the fall was unwitnessed. A review of the neuro checks revealed the same set of vitals taken at the time of the fall at 4:00 AM were used again for the checks done at 4:30 AM and 5:00 AM. Further review revealed the same set of vital signs taken with the 7:00 AM neuro check was used for the rest of the neuro checks done every 30 minutes from 7:00 AM until 3:00 PM instead of vital signs being checked with each neuro check. Review of the Post-Fall Review, dated 08/27/2021, revealed the resident had a witnessed fall at 1:30 PM. A review of the neuro checks revealed the first neuro checks and vital signs were not obtained until 2:30 PM, and the vital signs used for the neuro checks from 2:45 PM until 5:30 PM, done every 15-30 minutes, were all the same. A further review revealed the same set of vital signs taken on 08/27/2021 at 6:30 PM were used for all the neuro checks done through 08/29/2021 at 4:15 PM instead of vital signs being checked with each neuro check. Interview with Licensed Practical Nurse (LPN) #7, on 09/01/2021 at 2:24 PM, revealed that if a resident had an unwitnessed fall or a suspected head injury, neuro checks should be done every 15 minutes for an hour, then every half an hour for two (2) hours, every hour for four (4) hours, then every eight (8) hours for three (3) days. She said every part of the neuro checks was important, from the size and reaction of the pupils to the movement of the extremities, including the vital signs, because any change could indicate a possible injury. Interview with LPN #88, on 09/02/2021 at 9:07 AM, revealed neuro checks were to be done on any resident that had an unwitnessed fall, hit their head, or had a suspected brain injury. She said the checks should be done every 15 minutes times four (4), every 30 minutes times four (4), every hour times four (4); and then every six (6) to eight (8) hours for a total of three days. She said the computer system prompted the nurse as to which assessment was due. She said vital signs were very important to determine a change in the resident's condition and should be taken every time a neuro check was done. Interview with the Director of Nursing (DON), on 09/02/2021 at 10:30 AM, revealed neurological checks should be done if a resident hit their head during a fall or with any unwitnessed fall. She said she was not sure how often the neuro checks should be done, but it should be done over the course of three (3) days. She said vital signs were a very important part of the assessment to determine if the resident was having a change of condition. She said a new set of vital signs should be obtained with each neuro check, and it was not acceptable to use vital signs taken at a different time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's policy, titled, Behavior Monitoring Policy, dated 03/22/2021, revealed in pertinent part, behaviors should be documented clearly and concisely by facility staff. Documentation should include specific behaviors, time and frequency of behaviors, observation of what may be triggering behaviors, what interventions were utilized, and the outcomes of the interventions. Review of the facility's policy, titled, Use of Psychotropic Drugs Policy, dated 03/22/2021, revealed in pertinent part, residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record, and unless the medication is beneficial to the resident as demonstrated by monitoring and documentation of the resident's response to the medication. Record review revealed the facility admitted Resident #55 on 03/16/2021 with diagnoses that included cystitis, chronic obstructive pulmonary disorder, type 2 diabetes, traumatic subdural hemorrhage, depression, and dementia with behavioral disturbance. Review of Resident #55's Care Plan, revealed a behavior problem was initiated on 08/12/2021. This was related to the resident not wanting to turn in their lighter once they finished smoking, refusing care at times, and being resistive to care related to dementia. Interventions included: observing for behavior episodes and attempting to determine the underlying cause, consider location, time of day, persons involved, and situations, and document the behavior and potential causes. Review of Resident #55's Care Plan, revealed a problem of impaired cognitive function/dementia or impaired thought processes related to dementia without behavioral disturbance. This was initiated on 03/16/2021 and revised on 07/12/2021. Further review revealed a problem of depression and anxiety related to the dementia disease process, and an old cardiovascular accident with a present slow bleed. This was initiated on 03/17/2021 and revised on 07/27/2021. Interventions for both of the above problems included documenting/reporting, as needed, the following: any risk for harm to self, suicidal plan, past attempt at suicide, risky actions, intentional harm or tried to harm self, refusing to eat or drink, refusing medications or therapies, sense of hopelessness or helplessness, impaired judgement, or safety awareness. Continued review of the care plan, revealed a problem of using psychotropic medications related to behavior management, disease process, refusing care, and wandering. This was initiated 03/17/2021 and revised on 08/30/2021. Interventions included documenting/reporting any adverse reactions of psychotropic medications, as needed. Review of Resident #55's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was six (6), which indicated severe cognitive impairment. The resident had symptoms of feeling or appearing down, depressed, or hopeless for two (2) to six (6) days. The resident had no physical, verbal, or any other behavior exhibited towards others. Review of Resident #55's Medication Administration Record (MAR), dated September 2021, revealed an order for a Seroquel tablet at 100 milligrams (mg) with a start date of 08/18/2021. The order indicated to give 100 mg by mouth three times a day for major depressive disorder. A further review revealed an order to monitor for potential side effects related to antipsychotic use every shift. There was no order for routine behavior monitoring related to antipsychotic medication use. Review of Resident #55's Treatment Administration Record (TAR), dated September 2021, revealed an order to monitor for potential side effects related to antipsychotic use every shift. There was no order for routine behavior monitoring related to antipsychotic medication use. A review of Resident #55's Certified Nurse Aide (CNA) behavior monitoring paperwork for the previous 3 months revealed: - June 2021: three (3) behavior alerts on 06/29/2021 for abusive language, rejection of care, and exhibiting threatening behavior. - July 2021: one (1) behavior alert on 07/17/2021 for exhibiting yelling/screaming. - August 2021: four (4) behavior alerts on 08/09/2021 for exhibiting abusive language, pinching/scratching/spitting, exhibiting threatening behavior, and exhibiting wandering. One (1) behavior alert on 08/16/2021 for exhibiting wandering. And three (3) behavior alerts on 08/18/2021 for exhibiting abusive language, exhibiting threatening behavior, and exhibiting wandering. Further review of the documents revealed behavior alerts on the CNA behavior monitoring paperwork were not targeted behaviors specific to the resident. The CNAs were not observing for any specific behaviors. These behavior alerts were not associated with the Seroquel medication. Review of Resident #55's Nurse's Notes, dated 06/01/2021 to 09/01/2021, revealed there were no associated Nurse's Notes to the behavior alerts on the CNA behavior monitoring paperwork. There were no Nurse's Notes indicating the resident had behaviors. Interview with Certified Nurse Aide (CNA) #66, on 09/02/2021 at 12:11 PM, revealed Resident #55 got agitated at times and sometimes yelled. Nothing seemed to trigger the yelling. He further stated he did not do anything to monitor the resident's behaviors. Interview with Licensed Practical Nurse (LPN) #7, on 09/02/2021 at 12:14 PM, revealed Resident #55 did have some behaviors when he/she could not smoke. When the resident first came to the facility, the/she was an independent smoker, but the resident had declined since then and now must be supervised. Further review revealed Resident #55 would become agitated when he/she could not smoke, and his/her behaviors had increased, starting about a month ago. She further stated they monitored Resident #55's behaviors every shift, and it should be on the TAR to check off every shift. However, review of the behavior monitoring check off on the TAR revealed there was no monitoring documented. Interview with the Director of Nursing (DON), on 09/02/2021 at 9:45 AM, revealed she would have to look at the most recent psychiatric notes when asked why Resident #55 was taking Seroquel for depression, because it was an antipsychotic medication. The DON further stated any behaviors residents have would be in the CNA documentation. She stated she was in the process of updating the MAR with behavior monitoring. The DON stated it should be in the Physician's Orders Section, and she had not yet put it on Resident #55's MAR. Based on interviews, record reviews, and review of facility policies, it was determined the facility failed to ensure residents were free from unnecessary psychotropic medications for two (2) residents of five (5) residents reviewed for unnecessary medications (Resident #2 and Resident #55). Specifically, the facility failed to monitor behaviors present for the use of psychotropic medications and offer non-pharmacological interventions for Resident #2; and failed to monitor Resident #55's behaviors when using an antipsychotic medication for depression. This deficient practice could affect the 11 residents who were being administered antipsychotic medications. The findings included: 1. Review of the facility's policy titled, Use of Psychotropic Drugs, implemented 03/22/2021, revealed the indications for the use of any psychotropic drug should be documented in the medical record and should include the specific condition as diagnosed by the physician, non-pharmacological interventions that have been attempted and target symptoms for monitoring. Residents who use psychotropic drugs shall receive non-pharmacological interventions to facilitate the reduction or discontinuation of the psychotropic drugs. Record review revealed the facility admitted Resident #2 on 09/22/2020 with diagnoses which included cerebral infarction (stroke), dementia with behavioral disturbance, major depressive disorder, and generalized anxiety. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/18/2021, revealed Resident #2's cognition was severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) out of fifteen (15). A further review indicated the resident received antipsychotic, antidepressant, and antianxiety medications seven (7) out of seven (7) days during the 7-day assessment period. Review of Resident #2's physician orders. revealed the resident had orders for buspirone (an antianxiety) 10 milligrams (mg) one tablet two times a day for anxiety, ordered 09/22/2021, fluoxetine (an antidepressant) 40 mg one tablet one time a day for mood disorder, ordered 09/23/2021, and quetiapine fumarate 25 mg 0.5 tablet at bedtime for depression related to dementia with behaviors, ordered 07/15/2021, with orders to monitor for potential side effects related to antipsychotic use. The quetiapine was discontinued on 08/26/2021 after a gradual dose reduction. Review of Resident #2's medical record revealed no behavior monitoring was being done to indicate the need for any of the psychotropic medications. The side effects of the antianxiety and antidepressant medications were not being monitored. Review of progress notes, from 06/01/2021 through 09/01/2021, revealed no documentation of behaviors exhibited by the resident. No non-pharmacological interventions were documented as being attempted. Review of the comprehensive care plan, initiated 09/20/2020 and last revised 08/16/2021, revealed the resident had a mood problem, anxiety, and depression and took psychotropic medications. Interventions included to administer medications as ordered by physician; watch for and document side effects and effectiveness every shift; report any issues to the physician; consult with pharmacy and physician to consider dosage reduction when clinically appropriate, at least quarterly; and record/report to the physician as needed mood patterns, signs, and symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols. Interview with Licensed Practical Nurse (LPN) #7, on 09/01/2021 at 2:24 PM, revealed behaviors were documented in the progress notes or on the daily skilled charting, and they charted by exception only - meaning behaviors would only be charted if they occurred. She said nursing administration determined what behaviors should be monitored. She said side effects of psychotropic medications should be monitored and this was documented on the medication administration record (MAR). Interview with LPN #88, on 09/01/2021 at 2:45 PM, revealed behavior monitoring would depend on the resident's specific medication. She said they charted behaviors by exception, and it was case-by-case with each resident. She said she would try and chart any behaviors that were different from their baseline if they had been in the facility for a while. She said if the resident was a new admission, she would review the chart to determine what behaviors the resident had. LPN #88 said Resident #2 had behaviors of delusions and rejecting care. She said Resident #2 had been on an antipsychotic medication since she was admitted , but it made the resident very drowsy, so the physician started decreasing the dose a couple of month ago. She said the medication was administered at night, so she was not aware the medication had been discontinued. She said monitoring of side effects of psychotropic medications was usually documented on the MAR. After reviewing Resident #2's record, she agreed no monitoring for the side effects of Resident #2's antianxiety or antidepressant were being documented. She said they did not document the use of non-pharmacological interventions prior to using an as needed psychotropic medication. Interview with the Director of Nursing (DON), on 09/02/2021 at 10:30 AM, revealed behavior monitoring should be occurring with any resident on a psychotropic medication. She said the monitoring should be behavior specific for the individual resident for each medication and should be documented every shift on the MAR. She said the IDT determined what behaviors to monitor. She said non-pharmacological interventions should be attempted and documented in the resident's record. She said non-pharmacological interventions depended on what the resident's behavior was but could include family visits, activities to keep the residents busy, changing the environment and ensuring the resident's comfort. She said the side effects of psychotropic medications should be monitored every shift and documented on the MAR. The DON said she did not know what behaviors the staff should be monitoring Resident #2 for.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and facility policy review, it was determined the facility failed to provide dental services for one (1) of one (1) sampled resident (Resident #7) who had missing and broken teeth. The findings included: Review of the facility's policy, titled, Dental Services, dated December 2016, indicated that routine and emergency dental services were available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Record review revealed the facility admitted Resident #7 on 05/24/2021 with diagnoses which included atherosclerotic heart disease, type 2 diabetes, and hypertension. Review of the admission Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was ten (10), which indicated moderate cognitive impairment. According to the MDS, there were no issues with the resident's teeth. Review of the admission Nursing Bundle, document, revealed Resident #7 did not have any issues with their teeth. The Dental/Nutrition section was marked none of the above. Interview with Resident #7, on 08/30/2021 at 12:21 PM, revealed he/she did not have any teeth on the top and they were missing some teeth on the bottom. During the interview, the resident opened their mouth and missing and broken teeth were observed. The resident stated they would like to see a dentist. Interview with the Assistant Director of Nurses (ADON), on 09/02/2021 at 8:53 AM, revealed all residents were screened upon admission using the admission Bundle, which was a detailed form in the resident's clinical record to record health status which included dental questions. She verified the assessment for Resident #7 noted none was marked under the Dental/Nutrition section, indicating there were no issues with Resident #7's teeth. She asked the resident if she could examine the resident's mouth and teeth. After getting the resident's agreement, she put on gloves and looked at the resident's mouth and teeth. Resident #7 stated there was no pain, but there had been difficulty chewing. The ADON stated that there were several missing teeth and a couple teeth were broken. She stated the resident needed a dental consult due to missing and broken teeth. Interview with Licensed Practical Nurse (LPN) #41, on 09/02/2021 at 9:16 AM, revealed she was working on the next Quarterly MDS. She stated that Resident #7 had previously stated that there had been trouble chewing meats, and she talked to the Dietary Manager (DM) to get the resident changed to a mechanical soft diet. Resident #7 was then able to eat the ground meat easier. She stated that if the assessment had been documented correctly, the resident would have been referred to the dentist. Interview with the Social Worker, on 09/02/2021 at 9:38 AM, revealed the dentist came approximately every four (4) months, but residents could also be sent out for dental care if needed. The Social Worker stated the goal was to have every resident seen by a dentist at least yearly. The Dental Services policy did not indicate a routine system for referral of residents with problems related to their natural teeth. The Social Worker indicated they would be seen as needed. Interview with Speech Therapist #99, on 09/02/2021 at 9:47 AM, revealed Resident #7 was on the regular caseload and received a mechanical soft diet. She stated Resident #7 always denied having oral pain. She had not looked at the resident's mouth after the resident was added to the therapy caseload. Interview with LPN #7, on 09/02/2021 at 10:34 AM, revealed that Resident #7 chose to receive a mechanical soft diet and had never mentioned teeth problems to her. Interview with the Director of Nursing (DON), on 09/02/2021 at 10:09 AM, revealed it would be poor dentition if a resident had missing or broken teeth and she had never heard that this resident could not chew meats. She was unsure what the nurse who did the assessment was thinking when she marked Resident #7 as none for dental issues. She would have expected a diet change, and this would not be an emergent reason to see the dentist. She indicated that the resident would have been seen routinely for dental care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and facility policy review, it was determined the facility failed to follow transmission-based precautions for source control and personal protective equipment (PPE) for four (4) of twenty-two (22) residents sampled for infection control (Resident #384, Resident #385, Resident #53 and Resident #21). This deficient practice occurred during the COVID-19 pandemic and had the potential to affect all residents by placing them at risk of COVID-19 transmission. The facility failed to ensure hand hygiene and other appropriate measures were taken by staff to prevent the transmission of disease during the medication pass. This affected three (4) (Residents #50, Resident #69, Resident #82 and Resident #76) of five (5) residents observed receiving medication and/or a finger stick blood sugar (FSBS) during the medication pass observation. The findings included: Review of the facility's policy, titled The Transmissions Based Precautions Policy, dated 03/22/2021, revealed in pertinent part: 4. Droplet Precautions, e. residents on droplet precautions who must be transported outside of the room should wear a mask if tolerated. Further review revealed donning PPE upon room entry and discarding before exiting the room is done to contain pathogens. 1. Record review revealed Resident #384 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disorder, Acute Respiratory Failure, Congestive Heart Failure, and Anxiety. No Minimum Data Set (MDS) had been completed for the resident. Review of Resident #384's medical record on 08/30/2021, revealed Resident #384 declined the COVID-19 vaccine. Review of Resident #384's Physician's Orders on 08/30/2021, revealed no orders for isolation or droplet-based precautions. Review of Resident #384's Care Plan, revealed that the resident would be on droplet isolation for 14 days from admission due to their recent admission to the facility. This was initiated on 08/30/2021. Interventions included that in addition to standard precautions, wear a mask when working within three (3) feet of the resident or if necessary, prior to entering the room. Limit the movement and transport of the resident from the room to essential purposes only. Observation on 08/30/2021 at 9:35 AM, revealed a droplet-precautions sign on the exterior of Resident #384's door. The door to the room was open and the sign faced the wall. Observation on 08/30/2021 at 10:15 AM, revealed Occupational Therapist (OT) #93 in Resident #384's room wearing only a surgical mask. No gown, gloves, face shield, or shoe covers were worn. Interview with Occupational Therapist (OT) #93, on 08/31/2021 at 1:07 PM, revealed she did therapy with Resident #384 in the resident's room and in the therapy gym. When asked what she wears in the resident's room, OT #93 stated she wore a gown and gloves in the room, and if she left the room, she disrobed and sanitized her hands. She further stated Resident #384 wore a mask during therapy in the gym. When asked when she was trained on droplet precautions when working with residents, OT #93 stated she was told that morning. OT #93 further stated she was not told Resident #384 was on droplet precautions before this. When asked why she did not have the additional PPE on when in Resident #384's room the previous day, she stated because there was no sign on the door. She thought there was probably a sign there now with a cart out front with PPE in it. Observations on 08/30/2021 at 12:00 PM and 3:30 PM, revealed Resident #384 in common areas with other residents and on the resident's hall wearing no mask or other PPE. Observation on 08/30/2021 at 2:05 PM, revealed the door of Resident #384's room had adroplet isolation sign posted on the outside. A family member was observed to walk out of the room wearing a mask and no additional personal protective equipment (PPE). The family member was asked if they were required to wear a gown or any other PPE while visiting the family member. The family member stated no staff had told them to wear any additional PPE other than the mask to enter the resident's room. Interview with Resident #385's unidentified Family Member, on 08/30/2021 at 2:05 PM, stated their family member had only been in the building for about five (5) days. They further stated they did not know their family member was in isolation and did not know why. They stated they were only told to wear a mask and check in at the front door before going to the room. They further stated the family member and Resident #385 were fully vaccinated and have been since Spring 2021. Observation, on 08/31/2021 at 8:15 AM, revealed no droplet precaution sign on the exterior of Resident #384's room. Interview with Resident #384, on 08/30/2021 at 3:30 PM, revealed he/she did not really wear a mask. Resident #384 stated nursing staff would wear a gown and extra stuff when they were in his/her room but therapy never did. Resident #384 further stated they had never been told to wear any PPE when out of the room. The resident stated he/she had participated in group activities like bingo and music. Interview with Licensed Practical Nurse (LPN) #33, on 08/30/2021 at 9:30 AM, revealed full PPE of a gown, gloves, masks, face shield, and shoe covers must be worn in every resident's room who was on droplet precautions. She further stated Resident #384 was on droplet precautions. Interview with Registered Nurse (RN) #86, on 08/30/2021 at 2:25 PM, who was the facility's Infection Control Preventionist, revealed when a resident was on isolation, staff should wear a mask and gown in the rooms. There were signs on the door and PPE was supposed to be in the boxes outside of the room. When asked if residents on isolation could leave the room, he stated it was highly encouraged for them to stay in their rooms, but if they did come out, they asked them to wear a mask. RN #86 further stated new admissions who had been vaccinated past the 14-day mark, per Kentucky protocols, were not put on isolation. He further stated therapy staff were required to wear the same PPE as other staff when in the room. Staff knew they were supposed to wear the PPE and they had the list of residents who were on isolation. Further interview revealed they knew about the isolation because this information was passed on in report and there was a sign on the door. Interview with Personal Care Assistant #73, on 08/30/2021 at 3:25 PM, revealed he did not know that Resident #384 was on droplet precautions because he had never seen a sign as the resident's door was always open. He further stated no one had told him the resident was on droplet precautions, and he had been in the room a few times to deliver and pick up trays. 2. Record review revealed the facility admitted Resident #385 on 08/25/2021 with diagnoses including Alzheimer's, Congestive Heart Failure, Dementia, Anemia, Anxiety, Hypertension, and Jyperlipidemia. Review of Resident #385's care plan, revealed the resident was at risk of respiratory infection and was on droplet precaution isolation related to possible exposure to COVID-19. This started at the time of admission and was to last for 14 days. This was initiated on 08/25/2021 and the problem was created on 08/30/2021. Further review revealed a problem of impaired cognitive function or impaired thought processes related to Alzheimer's. This started on 08/26/2021. Observation on 08/30/2021 at 2:00 PM, revealed a droplet-precautions sign on the exterior of Resident #385's room. The door to the room was open and the sign faced the wall. A further observation revealed an unidentified family member visiting in the room, wearing only a surgical mask. Review of Resident #385's medical record, on 08/30/2021, reflected no COVID-19 vaccination status. Interview with Registered Nurse #86, on 08/30/2021 at 2:25 PM, who was also the facility's Infection Control Preventionist, stated when a resident was on isolation, staff should wear a mask and gown in the rooms. There were signs on the door and PPE was supposed to be in the boxes outside of the room. They encouraged family members to don the same PPE as staff. Families were notified of the isolation upon admission. Staff knew they were supposed to wear the PPE and they had the list of residents who were on isolation. They knew about the isolation because this information was passed on in report and there was a sign on the door. He further stated they encouraged nursing staff to speak with family members on wearing PPE and they have the signs on the doors. Interview with the Infection Preventionist, On 08/30/2021 at 2:31 PM, revealed she was responsible for educating visitors about the requirement to don PPE prior to entering the room of a resident receiving droplet precautions. She further stated nursing staff were also encouraged to educate visitors for residents receiving transmission-based precautions. 7. Record review revealed the facility admitted Resident #21 on 06/18/2021 with diagnoses including Cirrhosis, Arthritis, and Cardiovascular Accident. Observation on 08/31/2021 at 1:01 PM, revealed as lunch was being served, Certified Nursing Assistant (CNA) #45 was observed taking a lunch tray into Resident #21's room. Outside the door was a plastic cart containing personal protective equipment (PPE) and a droplet precaution sign was on the outside of the door. CNA #45 went in without donning PPE. Interview with CNA #45, on 08/31/2021 at 1:05 PM, revealed that due to a resident in that room being on isolation precautions, he should have put on the gown and gloves in addition to his face shield. He indicated that he did not notice that the sign had been added to the door. He stated that he had been trained to put on required PPE prior to going into a room with any isolation precaution notation on the door. Interview with the Staff Development Coordinator (SDC)/Infection Control Coordinator, on 09/02/2021 at 8:47 AM, revealed staff had been trained and were expected to wear complete PPE when entering any room with isolation precautions and remove the PPE prior to leaving the room. 8. Review of the facility's policy, titled, Transmission-Based Precautions, dated 03/21/2021, revealed in pertinent part: 4. Droplet precautions: Residents on droplet precautions who must be transported outside of the room should wear a mask if tolerated. The Centers for Disease Control (CDC) guidelines, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, last revised on 09/10/2021, indicated: 1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic - Implement Source Control Measures - Source Control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. - Source control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting. Review of the CDC COVID Data Tracker, as of 09/02/2021, the facility's county was in high community transmission, and the entire state of Kentucky was experiencing high community transmission. Interview with the Director of Nursing (DON), on 09/01/2021 at 2:35 PM, revealed if a resident was on droplet precautions, they would need to stay in their room, but when they needed to leave their room, they should be wearing a mask. Interview with the Nursing Home Administrator (NHA), on 09/01/2021 at 2:35 PM, revealed they expected the facility's infection control policies to be followed, and the resident should have been educated and wearing a mask in the hallways. 3. Record review revealed the facility admitted Resident #53 on 10/22/2020 with diagnoses which included Chronic Kidney dDisease and Diabetes Mellitus. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 07/31/2021, revealed the resident's Brief Interview for Mental Status (BIMS) score was fifteen (15), which indicated the resident was cognitively intact and interviewable. The resident received dialysis. Review of Resident #53's care plan, dated 07/30/2021, indicated the resident was on droplet isolation continuously due to going to appointments several times a week. The resident was at risk for being exposed to COVID-19. The interventions included: In addition to standard precautions, wear a mask, gown, and gloves when entering the room. Encourage the resident to wear a mask, especially when needing to be out of the room and out of the building to appointments. The resident may refuse to do so. Ensure the mask is clean and functional and change as needed. Record review revealed Resident #53 was not fully vaccinated for COVID-19, having received only one dose. Observation on 08/30/2021 at 12:15 PM revealed Resident #53 in their wheelchair next to the nurse's station. Resident #53 was not wearing a mask and was talking to a staff member behind the nurse's station. Observation on 08/31/2021 at 7:11 AM, revealed Certified Nurse Aide (CNA) #12 entered and exited the room of Resident #53, who had a droplet isolation sign posted on the outside of the door. CNA #2 was wearing a surgical mask as personal protective equipment (PPE). When asked if they were required to wear any additional PPE, CNA #12 stated they had not been told to wear any additional PPE to enter the rooms of residents receiving transmission-based precautions. A PPE container was sitting in the hall outside the room of Resident #53. Interview with Resident #53, on 08/30/2021 at 4:32 PM, revealed they had been in the facility for close to a year and was not aware of any precautions due to having to go to dialysis. Resident #53 further stated he/she had not seen anyone dress up in all that stuff (gown, goggles, gloves, mask, and shoe covers) until that day. 4. Review of the facility's policy, titled, Hand Hygiene, implemented 03/24/2021, revealed, All staff would perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applied to all staff working in all locations within the facility. Staff would perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. Alcohol-based hand rub with 60-95% alcohol was the preferred method for cleaning hands in most clinical situations Observation on 08/31/2021 at 7:25 AM, revealed Licensed Practical Nurse (LPN) #88 setting up medications to administer to Resident #50. Further observation revealed while attempting to find the resident's medication cards in the drawer of the medication cart, the LPN adjusted the nose piece of her mask and, without washing her hands or using hand sanitizer, proceeded to set up the medications. Observation on 08/31/2021 at 7:32 AM, revealed LPN #88 removed scissors from her pocket to cut off the end of fish oil capsules. Further observation revealed she failed to sanitize the scissors prior to cutting the end from the capsule to allow her to squeeze the medication into the medication cup. When asked if she had cleaned her scissors prior to cutting the end of the capsules, the LPN stated the scissors had been sanitized earlier. When asked if her pocket was sanitary, she stated it was not and acknowledged she had not sanitized the scissors prior to cutting the capsule. Interview with LPN #88, on 09/01/2021 at 12:06 PM, revealed when asked if, once donned, her mask would be considered sanitary to touch. The LPN stated, No, it's probably not. When asked if she should wash her hands or use hand sanitizer after touching her mask and before continuing to set up medications, the LPN stated, Yes. Interview with the Director of Nursing (DON), on 09/01/2021 at 1:43 PM, revealed once donned, a mask was considered to contaminated. When asked if she would expect staff to wash their hands or use hand sanitizer after touching/adjusting their mask and before touching anything else, she stated, Yes. When asked if LPN #88 would have been expected to clean her scissors prior to cutting the capsule for Resident #50, the DON stated, Yes. 5. Observation and interview on 08/31/2021 at 7:54 AM, 8:06 AM, and 8:09 AM, revealed Licensed Practical Nurse (LPN) #7 adjusted the nose piece of her mask while standing in front of the medication cart. Without washing her hands or using hand sanitizer after each time she touched the mask, the LPN proceeded to set up medications. As the LPN passed by with the medications, she adjusted the nose piece of her mask and stated she tried to keep the mask over her nose but had difficulty doing so. Observation on 08/31/2021 at 8:11 AM, revealed LPN #7 was adjusting her mask while standing at the bedside of Resident #69 just prior to administering an eye drop to the resident. The LPN did not wash her hands or use hand sanitizer prior to administering the eye drop. Interview with Licensed Practical Nurse (LPN) #7, on 09/01/2021 at 12:07 PM, revealed when asked if, once donned, her mask would be considered sanitary to touch. She stated, No. When asked if she should wash her hands or use hand sanitizer after touching her mask and before continuing to set up medications, the LPN stated, Yes. Interview with the Director of Nursing (DON), on 09/01/2021 at 1:43 PM, revealed once donned, a mask was considered to contaminated. When asked if she would expect staff to wash their hands or use hand sanitizer after touching/adjusting their mask and before touching anything else, she stated, Yes. 6. Review of the facility's policy, titled, Obtaining a Finger stick Glucose Level, revised 10/2011, revealed, Wash the selected fingertip, especially the side of the finger, with warm water and soap. (Note: If alcohol is used to clean the fingertip, allow it to dry completely because the alcohol my alter the reading. Repeated use of alcohol may toughen the skin Observation on 08/31/2021 at 4:05 PM, revealed Licensed Practical Nurse (LPN) #9 was observed as they performed a finger stick blood sugar (FSBS) for Resident #82. Prior to using the lancet, the LPN did not use an alcohol swab to sanitize the resident's finger. When the first finger stick did not bring blood, the LPN used another lancet to stick another finger. Again, the LPN did not sanitize the resident's finger prior to the finger stick. When asked if they were required to clean the resident's finger with alcohol prior to using the lancet, LPN #9 stated, Yes, and acknowledged they had not sanitized the resident's finger either time prior to using the lancet. Interview with the DON, on 09/01/2021 at 1:43 PM, revealed when the above observations and the facility's FSBS policy and procedure were reviewed with the Director of Nursing (DON). When asked if nursing staff would be expected to use an alcohol swab to clean a resident's finger prior to a finger stick, the DON stated, I would expect them to follow policy. I would expect them, at a minimum, to use an alcohol swab if [LPN #9] didn't consider soap and water.

Based on observations, interviews, record reviews, and facility policy review, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety. This deficient practice could put the 77 residents who receive meals from the facility kitchen at risk for nausea, vomiting, and foodborne illness. Oberservations during intial tour on 08/30/2021: A. Expired food was found in storage, and the Certified Dietary Manager (CDM) used expired three (3) compartment sink sanitizer test strips to verify concentration. B. Raw foods were found stored next to ready-to-eat foods in the walk-in refrigerator. C. Kitchen staff failed to label and date leftover items. D. Kitchen staff failed to practice proper hand washing techniques and glove use. E. Food was stored within six (6) inches of the floor and 18 inches of the ceiling. F. Kitchen staff failed to wear a complete hair covering at all times when in the kitchen. G. Dry storage food items were not sealed and were open to air. H. Personal items were found stored on food preparation tables and next to food and dish storage. I. Dented cans were found in dry storage. J. Kitchen staff failed to maintain overall kitchen cleanliness. K. Facility staff failed to handle cups on the outside of the container away from mouth contact surfaces. The findings included: A. Review of the undated facility's policy, titled Food Preparation revealed in pertinent part, time/temperature controls for safety. Foods that were to be held for more than 24 hours at a temperature of 41 degrees Fahrenheit or less will be labeled and dated with a prepared date (Day 1) and a use by date (Day 7). Observations during the initial tour, on 08/30/2021 from 8:30 AM to 9:00 AM, revealed eight (8) cartons of liquid eggs with a use-by date of 07/15/2021, two (2) five- (5) pound containers of cottage cheese with a best-by date of 07/26/2021, a box of fresh green bell peppers with a black and white growth on them stored next to pasteurized shelled eggs, and a container of fruit cocktail with a use-by date of 08/27/2021. All of these items were observed in the reach-in refrigerator. A further observation revealed the CDM using test strips with an expiration date of 02/2020 to measure the concentration of the sanitizer in the three- (3) compartment sink. Interview with the CDM, on 08/30/2021 at 8:45 AM, confirmed the liquid eggs, cottage cheese, and green bell peppers were expired. She stated she would discard these items. Interview with the CDM, on 09/01/2021 at 9:24 AM, revealed she expected her staff to adhere to the standards for food storage. Everything should be labeled and dated, they should use items first-in-first-out, and she always tried to talk to them about expiration dates. She stated if her staff were labeling and dating, then they will be more aware of expiration dates. B. Observations during the initial tour, on 08/30/2021 from 8:30 AM to 9:00 AM, revealed uncooked pasteurized shelled eggs stored on a shelf of the walk-in refrigerator next to fresh lettuce. A further observation revealed two (2) boxes of pre-packaged ham lunch meat stored on the bottom shelf next to four (4) ten-pound logs of raw ground beef, and a box of green bell peppers stored on the bottom shelf of the walk-in refrigerator next to shelled eggs. C. Observations during the initial tour, on 08/30/2021 from 8:30 AM to 9:00 AM, revealed a container of leftover food with no date or label and half a steam table pan with a brown substance in it with no label or date. Interview with the CDM, on 08/30/2021 at 8:45 AM, revealed she would discard the food items in the containers with no date or label because there was no way to tell how old they were. Interview with the CDM, on 09/01/2021 at 9:24 AM, revealed she teaches her staff to date foods when opened with their use-by dates. Leftovers should be used within three (3) days. When asked if they go by expiration dates on packages, the CDM stated, Not really. They only go by when they are opened, and then must be used within a certain time frame. D. Review of the undated facility policy, titled, Food Preparation revealed the Dining Services Director ensures that all staff practice the proper hand washing technique. Further review revealed the Dining Services Director or Cook(s) were responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. Review of the facility's document, titled, Handwashing Guidelines for Dietary Employees, dated as 2021 with no month, revealed in pertinent part, Dietary employees should clean their hands in a handwashing sink or approved automatic handwashing facility and may not clean their hands in a sink used for food preparation. Dietary employees should clean their hands after having touched anything unsanitary such as the garbage or soiled items, before donning gloves for working with food, and after engaging in any activity that may contaminate the hands. Interview with the CDM, on 08/30/2021 at 8:30 AM, revealed there were two (2) specified sinks for staff to wash their hands. One was in the food preparation area, and one was in the dish room with hand soap, paper towels, and a step on trash can. Observations on 08/31/2021 from 12:00 PM to 12:20 PM, revealed [NAME] #110 adjusted his surgical mask using a gloved hand and then proceeded to start plating from the steam table. He continued to use both gloved hands to handle sliced ham and bread rolls while placing them on plates. He then dropped a bread roll into a pureed food item on the steam table, picked it up with his gloved hand, and then lifted the trash lid to throw it out. He then removed his soiled gloves, threw them out and proceeded to wash his hands in the vegetable sink located next to the designated hand wash sink. [NAME] #110 then put on another pair of gloves and continued to use his gloved hands to place sliced ham and bread rolls onto plates while periodically adjusting his surgical mask, placing his hands on his hips, and using a white cloth to wipe the top of the steam table between handling ready-to-eat food. Interview with the CDM, on 09/01/2021 at 9:24 AM, revealed she expected her staff to adhere to the standards on handwashing and glove use. She stated she was always in-servicing on it, and if staff do something with gloves, such as touch their mask, they need to dispose of the gloves, wash their hands, and get another pair. The only time staff should not wear gloves was when they were cutting vegetables. E. A review of the facility's policy, titled Cold Food Storage Policy, dated October 2019, revealed in pertinent part, the Dining Services Director or [NAME] is responsible for storing all items six (6) inches above the floor and 18 inches below the sprinkler unit. A further review revealed the Dining Services Director or [NAME] ensures that all food items are stored properly in covered containers, labeled, dated, and arranged in a manner to prevent cross contamination. Observations during the initial tour on 08/30/2021 from 8:30 AM to 9:00 AM revealed six (6) crates holding four (4) one- (1) gallon milk containers each stacked on the floor of the walk-in refrigerator. More than 20 boxes of food were stacked in a pile on the floor of the walk-in freezer. A further observation revealed a crate of potatoes stored on the floor of the dry storage area. There was a continuous horizontal red line painted on the wall below the ceiling on each wall of the dry storage area. Three (3) boxes were stored above this red line, within 18 inches of the ceiling. During an interview on 08/30/2021 at 8:55 AM, the CDM stated the potatoes should be up on something, and that no items should be stored above the red line on the wall. During an interview on 09/01/2021 at 9:24 AM, the CDM stated it was not appropriate to store food on the floor; it should always be at least six (6) inches off the floor. F. A review of the undated facility policy, titled Staff Attire, revealed the Dining Services Director ensures that all staff members have their hair off the shoulders, confined in a hairnet or cap. Observations during the initial tour on 08/30/2021 from 8:30 AM to 9:00 AM revealed the CDM wearing a hairnet on top of her head with four (4) to five (5) inches of hair hanging out the back and not covered by the hairnet. An observation on 08/30/2021 at 11:50 AM revealed Dietary Aide (DA) #115 in the center of the kitchen with no hairnet on. His hair was approximately one (1) centimeter long. During an interview on 08/30/2021 at 11:51 AM, DA #115 stated he just took his hairnet off and proceeded to get a new hairnet. During an interview on 09/01/2021 at 9:24 AM, the CDM stated she expected her staff to always wear a hair covering when in the kitchen. G. An observation on 08/30/2021 at 8:50 AM revealed a 25-pound bag of panko breadcrumbs at room temperature unsealed and open to the air on the shelf below a preparation table. A further observation in the walk-in refrigerator revealed a container holding boiled eggs with the lid half off, exposing the eggs to open air. An observation on 08/30/2021 at 12:20 PM revealed multiple spice containers not sealed and open to the air next to the walk-in refrigerator. During an interview on 09/01/2021 at 9:24 AM, the CDM stated that all foods that were being stored should be covered. H. Observations during the initial tour on 08/30/2021 from 8:30 AM to 9:00 AM revealed a personal drink, cell phone, and speaker sitting on a shelf above the microwave. A further observation revealed a personal drink with no lid was on the preparation table next to containers of dry cereal. An observation on 08/30/2021 at 11:50 AM revealed a personal drink with no lid on the preparation table and a speaker next to the two (2) handled cup storage. A further observation revealed a cell phone on the preparation table next to the storage bowl, a phone on the table in front of the microwave, and a personal water jug on the table next to the steam table during the plating of the lunch meal. During an interview on 09/01/2021 at 9:24 AM, the CDM stated staff's personal items such as phones, keys, and drinks should be kept in the break area. Staff have lockers and no personal items should be in the food preparation area. I. A review of the facility's policy, titled Receiving Policy, dated October 2019, revealed the Dining Services Director or designee inspects all canned goods appropriately for dents, rust, or bulges, and segregates and clearly identifies all damaged goods for return to vendor or disposal as indicated. Observations during the initial tour on 08/30/2021 from 8:30 AM to 9:00 AM revealed two (2) dented cans of pineapple in the dry storage area. During an interview on 08/30/2021 at 9:00 AM, the CDM stated she would discard the dented cans of pineapple because they should not use them. During an interview on 09/01/2021 at 9:24 AM, the CDM stated she expected her staff to set dented cans to the side, mark them as dented, and then let her know. When asked if dented cans should be on the storage rack, the CDM stated they should not be on the rack and they should be set aside. J. Observations during the initial tour on 08/30/2021 from 8:30 AM to 9:00 AM revealed the stove's drip pan was full with a dark brown liquid. The back wall of a food preparation table was dirty with brown spots and food debris, and the floor of the walk-in refrigerator was covered with crumbs and food debris. An observation on 08/30/2021 at 11:50 AM revealed a fly swatter on top of the coffee machine. During an interview on 08/30/2021 at 11:52 AM, the CDM stated she did not know the fly swatter was there and knew they should not have it, but they have a lot of flies in the summer. Observation on 08/31/2021 at 12:00 PM, revealed a kitchen employee deep cleaning the walk-in refrigerator. Interview with the CDM, on 08/31/2021 at 12:02 PM, revealed she brought in an extra employee that day to help deep-clean the walk-in refrigerator and throw out old foods. Interview with the CDM, on 09/01/2021 at 9:25 AM, revealed she expected her staff to adhere to the standards in the kitchen. K. Observations on 09/01/2021 at 8:20 AM revealed Certified Nurse Assistant (CNA) #50 picking up multiple cups of juice to place them onto trays being delivered to resident rooms. CNA #50 picked them up by placing her fingers on the top portion of the cup that touches the lips when drinking. During an interview on 09/01/2021 at 8:25 AM, CNA #50 stated she only remembered being told to pick up the cups of juice by touching the side portions of the cup. On 09/01/2021 at 8:33 AM, Certified Nursing Assistant (CNA) #62 was observed taking a breakfast tray to Resident #13. As she added the beverages from the cart to the tray, she picked up the 4-ounce cup, which was sitting on the cart with no lid, with her bare hands by the top rim of the cup. She then took the tray into the resident's room and sat down and prepared to feed the resident. During an interview with CNA #62 on 09/01/2021 at 9:03 AM, she stated that the milk should have been covered while it was taken to the resident's room. She said that the proper way to pick the cup up would have been using the side and not touching the rim of the cup.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure one (1) of eighteen (18) sampled residents' privacy and confidentiality of his/her medical records when staff left open a computer screen with a resident's medical information visible to other residents and visitors walking by (Resident #125). The findings include: Review of facility policy titled, Protected Health Information (PHI), Safeguarding Electronic, last revised February 2014, revealed electronic protected health information (e-PHI) is safeguarded by administrative, technical and physical means to prevent unauthorized access to protected health information. Observation on 10/02/19 at 9:35 AM, revealed Licensed Practical Nurse (LPN) #1, was preparing to administer medications to Resident #125 and walked away from the computer screen with the resident's information on it and in view of anyone who passed by. Interview with Licensed Practical Nurse (LPN) #1, on 10/02/19 at 9:40 AM, revealed she was aware she should not have walked away from the computer screen without closing it out. Interview with the Director of Nursing ((DON), on 10/04/19 at 1:22 PM, revealed she expected staff to cover and close out documentation window of computer when they walk away.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure a medication error rate of less than five percent (5%). Observation of a medication pass revealed thirty-two (32) opportunities with three (3) errors which resulted in a nine percent (9%) medication error rate. The findings include: Review of facility policy titled Administering Medications, dated with revision December 2012, revealed that medications shall be administered in a safe and timely manner, as as prescribed. 1. Record review revealed the facility admitted Resident #21 on 04/24/19 with diagnoses which included Atrial Fibrillation, End Stage Renal Disease, Hypertension, Peripheral Vascular Disease, and Diabetes. Review of the October 2019 Physician's Order revealed to administer Eliquis (anticoagulant) 5 milligrams (mg) twice a day. Review of the October 2019 Medication Administration Record (MAR) revealed the morning Eliquis dose was to be given at 6:00 AM. However, observation on 10/02/19 at 9:06 AM, revealed Licensed Practical Nurse (LPN) #2 administered Eliquis 5 mg to the resident (approximately two {2} hours and six {6} minutes late). 2. Record review revealed the facility admitted Resident # 69 on 09/03/19 with diagnoses which included Gastroesophageal Reflux Disease. Review of October 2019 Physicians Orders revealed to administer Omeprazole (Proton-Pump Inhibitor) 20 mg at 6:00 AM. However, observation on 10/02/19 at 9:17 AM, revealed LPN #2 administered Omeprazole 20 mg to Resident #69 (approximately two {2} hours and seventeen {17} minutes late). 3. Record review revealed the facility admitted Resident #226 on 09/25/19 with diagnoses which included Hypothyroidism. Review of October 2019 Physicians Orders revealed to administer Levothyroxine ( Thyroid Hormone) 150 micrograms (mcg) two (2) pills by mouth to be given at 6:00 AM. However, observation on 10/02/19 at 9:13 AM, revealed LPN #2 administered Levothyroxine 150 mcg by mouth to Resident #226 (approximately two {2} hours and thirteen {13} minutes late. Interview with LPN #2, on 10/02/19 at 9:09 AM, revealed she was aware she was administering medications that were due to be given at 6:00 AM. She stated the medications should be administered between one (1) hour before the scheduled time up to one (1) after the scheduled time. She revealed she was running behind because it had been a busy night. Interview with the Director of Nursing (DON) on 10/03/19 at 2:36 PM, revealed the physician and families of the residents who had received late medication were notified.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. Observations of two (2) of two (2) medication carts revealed on cart contained one (1) vial of insulin and another cart contained one (1) bottle of eye drops; that were not dated when opened. The findings include: Review of facility policy titled, Administering Medications, last revised December 2012, revealed the expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container. 1. Observation of the medication cart on the four-hundred (400) wing, on 10/03/19 at 10:53 AM, revealed an opened bottle of Combigan eye drops that was not dated when opened. 2. Observation of a medication cart on one-hundred wing, on 10/04/19 at 10:03 AM, revealed an open vial of Lantus insulin that was not dated when opened. Interview with the Director of Nursing (DON) on 10/04/19 at 1:22 PM, revealed she expected staff to label medication containers when opened.